Dental Coverage
 Participant     Participant +1     Participant +2+ (Family)
SAG-AFTRA Health Plan
 Active Plan Member    
 
First Name
Middle Initial
Last Name
Marital Status
Single   Married   Legally Separated   Divorced
Date of Birth
(mm/dd/yyyy)
Gender
   Male   Female
Social Security Number
(no dashes, numbers only)
SAG-AFTRA Member ID
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
E-mail
User Name
(Used for online access)
Create a log-in Password
(Used for online access)
Effective Enrollment Date 01/01/2025

DEPENDENT INFORMATION

(Enter dependent information if applicable)

 

NAME

 

SEX

 

RELATIONSHIP

 

BIRTH DATE

 

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

No

 

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: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

Yes

No

 

DEPENDENT SIX INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

Yes

No

 

DEPENDENT SEVEN INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

Yes

No

 

Any data that you submit to Group Benefit Associates through this website will be processed and used as described in the Privacy Policy available at the following link: Privacy Policy. By checking the box to the left, you agree that you have read and understood the terms of the Privacy Policy, and that you are granting Group Benefit Associates permission to use your data in accordance with the terms of the Privacy Policy.