Dental Coverage
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SAG-AFTRA Health Plan
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Effective Enrollment Date 11/01/2022

DEPENDENT INFORMATION

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NAME

 

SEX

 

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STUDENT

 

DEPENDENT ONE INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

 

Yes

No

 

DEPENDENT TWO INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

 

Yes

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DEPENDENT THREE INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

 

Yes

No

 

DEPENDENT FOUR INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

Yes

No

 

DEPENDENT FIVE INFO: 

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Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

Yes

No

 

DEPENDENT SIX INFO: 

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F

M

 

 

 

 

(mm/dd/yyyy)

Yes

No

 

DEPENDENT SEVEN INFO: 

First Name 

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F

M

 

 

 

 

(mm/dd/yyyy)

Yes

No

 

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