Fillable Dental Verification Form (Eastern Michigan University)

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Dental Verification Form (Eastern Michigan University)

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2017 DENTAL VERIFICATION FORM
FOR DEPENDENT CHILDREN AGES 19-24
E
Employee name (Print) Employee ID
Employee Classification:
AC AH AP CA CP CS FA FM LE PE PS PT VF
Please indicate your intent to continue dental coverage for your dependent children below. There
is no cost for the dental coverage for your dependent children through the end of the year they
turn 25, provided they are an IRS dependent, as defined by the U.S. Internal Revenue Code,
and will be claimed on your 2017 Federal Income Tax Return. (Sponsored dependents are not
eligible for dental coverage.)
Please complete appropriate columns below.
Dependent Child Name
Birth Date
Continue
Dental
Coverage
Discontinue
Dental
Coverage
Reason
Other
Coverage
Ineligible
Employee Signature Date
Please return this form to the Benefits Office by October 31, 2016 before 4:00 p.m.
Failure to return this form will result in cancelation of your dependent’s coverage.
If you have any questions, please call (734) 487-3195 or email hr_benefits@emich.edu.
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Dental Verification Form (Eastern Michigan University)

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Completed 23 July 2020

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