BENEFIT ENROLLMENT

EMPLOYER NAME

EMPLOYEE NAME

DIVISION

SOCIAL SECURITY NUMBER(ENTER LAST FOUR DIGTS ONLY)

DATE OF BIRTH

GENDER

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MARTIAL STATUS

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MAILING ADDRESS

ADDRESS LINE 1

ADDRESS LINE 2

CITY

STATE

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ZIP

OPT-IN CONSENT

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PHONE

Phone

DATE OF HIRE

ANNUAL SALARY

SPOUSE

SPUSE'S FULL NAME

SPOUSE'S DATE OF BIRTH

SPOUSE'S SOCIAL SECURITY NUMBER

DEPENDENT

FULL NAME

GENDER

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DATE OF BIRTH

SOCIAL SECURITY NUMBER

RELATIONSHIP(SON/DAUGHTER/STEPCHILD/ETC.)

DEPENDENT

FULL NAME

GENDER

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DATE OF BIRTH

SOCIAL SECURITY NUMBER

DEPENDENT

FULL NAME

GENDER

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DATE OF BIRTH

RELATIONSHIP(SON/DAUGHTER/STEPCHILD/ETC.)

MEDICAL

CURRENT LEVEL OF MEDICAL COVERAGE

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Please check if you have declined coverage

I DECLINED MEDICAL COVERAGE

CHANGE IN MEDICAL COVERAGE

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INDICATE MEDICAL COVERAGE DATE

REASON FOR DECLINING MEDICAL COVERAGE

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DENTAL

CURRENT LEVEL OF DENTAL COVERAGE

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Please check if you have declined Dental coverage

I Declined Dental Coverage

CHANGE IN DENTAL COVERAGE

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INDICATE DENTAL COVERAGE EVENT DATE

REASON FOR DECLINING DENTAL COVERAGE

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VISION

CURRENT LEVEL OF VISION COVERAGE

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Please check if you have declined Vision coverage

I Declined Vision Coverage

CHANGE IN VISION COVERAGE

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INDICATE VISION COVERAGE EVENT DATE

REASON FOR DECLINING VISION COVERAGE

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Primary Beneficiary

All Primary Beneficiaries must equal 100%

1.FULL NAME

ADDRESS LINE 1

ADDRESS LINE 2

CITY

STATE

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ZIP

SOCIAL SECURITY NUMBER

PRIMARY BENEFICIARY PERCENT ALLOTED

RELATIONSHIP

2.FULL NAME

ADDRESS LINE 1

ADDRESS LINE 2

CITY

STATE

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ZIP

SOCIAL SECURITY NUMBER

PERCENT ALLOTTED

REALATIONSHIP

Contingent Beneficiary

FULL NAME

ADDRESS LINE 1

ADDRESS LINE 2

CITY

STATE

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ZIP

SOCIAL SECURITY NUMBER

PERCENT ALLOTTED

RELATIONSHP

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