Application for Voluntary Health & Dental Benefits

This section to be completed by member.

Please complete this section if you have eligible dependents.

Add any unmarried dependent children below.

Last Name * First Name * Relationship * Date of Birth (YYYY-MM-DD) * Gender *

Members must enroll according to their true family status. Once enrolled, members may not opt out (except in the event of duplicate group coverage).

If yes, please indicate