Fillable Member Dependent Tracking Enrollment Form Name of Group (Clovis Community College)

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Member Dependent Tracking Enrollment Form Name of Group (Clovis Community College)

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3333 Quality Dr., Rancho Cordova, CA 95670 I P: 800.852.7600
Member Dependent Tracking Enrollment Form
Name of Group (Employer) Clovis Community College_
Employee Name: __________________________________
last name, first name, middle initial
Employee Social Security Number: _____________________
Gender: __Male __Female
Date of Birth: ___________________
Effective Date:___________________
Type of coverage selected:
___ Employee only
___ Employee and one dependent
___ Employee and children
___ Employee and family
___ Waive Coverage
*Dependent Relationship Key
S
Spouse
C
Child
H
Handicapped Child
T
Student
Dependent First
Name
Dependent Last
Name
Dependent
Relationship*
Date of Birth
Gender
___________________________ ____________________
Employee Signature Date
Please return this form to your benefits administrator. Do not return to VSP.
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Member Dependent Tracking Enrollment Form Name of Group (Clovis Community College)

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Completed 20 September 2020

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