DENTAL TRANSACTION FORM
Orange County Self-Insured
Last Name First Name Middle
Street Address Social Security Number
City State Zip Date of Birth
Marital Status: Date of Marriage/Status
Single Married Widowed Divorced
Decline Coverage Date of Hire
Request Individual Enrollment Request Family Enrollment (complete dependent information)
Change Name – Previous Name: Date:
Change to Individual – Reason: Date:
Change to Family – Reason: Date:
Add a Dependent – Reason: Date:
Remove a Dependent – Reason: Date:
List Name of Dependent(s) to be added or removed
Note: Relationship: SP- Spouse; Dtr – Daughter; Son-Son; S/Son – Stepson; S/Dtr – Stepdaughter; L/G Legal Guardianship
Is your spouse employed by Orange County OR Orange County Community College? Yes No
YOU MUST PROVIDE PROOF for all dependents being added to your coverage for the first time; copy of
government issued marriage certificate if adding spouse, birth certificate(s), social Security card(s), legal
guardianship papers, etc. Remove dependents as soon as they are no longer eligible; you must remove ex-spouse
as soon as divorce is final. Copy of the divorce decree (first and last page) and ex-spouse’s current address are
required.
I understand that if I am required to make contributions as a result of this request, my employee contributions for
the benefit will be take on a pre-tax basis (IRS Section 125) unless I notify RISK Management, in writing, to the
contrary.
Signature: Date:
For RISK Use only:
Risk Management Division – Health Benefits Unit 615-3600 Rev 3/16
**Option Transfer 2017**
**Do not use after November 3, 2016**
