Fillable Dental-VisionEnrollmentForm2018 ORANGE COUNTY SELF-INSURED

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Dental-VisionEnrollmentForm2018 ORANGE COUNTY SELF-INSURED

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DENTAL/VISION ENROLLMENT FORM
Orange County Self-Insured
DENTAL
Family
Individual
Decline
VISION
Family
Individual
Decline
Last Name First Name MI
Street Address
Social Security Number
City State Zip Code
Marital Status: Single Married Widowed Divorced
Decline Coverage
Request Enrollment – Individual
Request Enrollment – Family Complete Dependent Information
Change Name – Previous Name Was:
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
Last Name
First Name/ MI
Date of Birth
Relationship
Social Security No.
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 most recent 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 taken on
a pre-tax basis (IRS Section 125) unless I notify Risk Management, in writing, to the contrary.
SIGNATURE: DATE: _______________________________
Department:________________________________________________________________________________
For Risk Use Only:
Risk Management Division – Health Benefits Unit – 615-3600 Revised 1/18
Group No.
Dept No.
Effective Date
Documents on File
O.C.S.I
EH
EX
EL
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Dental-VisionEnrollmentForm2018 ORANGE COUNTY SELF-INSURED

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Completed 26 February 2020

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