Application for Voluntary Health & Dental Benefits

This section to be completed by member.

Please note that you must be under age 70 to apply for coverage (some exceptions do apply)

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).