3601 W. Olive Ave., Burbank, CA 91505 • Mailing Address: P.O. Box 7830, Burbank, CA 91510-7830
P (800) 777-4013 • F (818) 953-9880 •
New Dependent Form
Please fax to the Participant Eligibility department at (818) 973-4465
Within 60 days of acquiring a new dependent (for example, a new child or spouse), please add them to your
Benefits Manager at or return this completed form to the Plan even if you do
not have the recorded marriage or birth certificate, which you can send later or upload online. Please note that
your new dependents will not have health insurance coverage until the Plan has received and approved all
required documents and your premium payment. If the amount of your premium changes due to the enrollment
of a new dependent, a new billing statement will be sent to you.
Required documentation
Spouse: Copy of the recorded marriage certificate
Child: Copy of the recorded birth certificate, adoption, or guardianship papers
Exception: We will accept a copy of the birth certificate from the hospital to add your biological child who is
younger than one year of age for a period not to exceed 120 days while you obtain a recorded copy.
Participant name
Date of birth
Health care ID (HCID) number
Please complete the following:
First and last name
List new dependent(s)
Date of birth
Relationship: spouse;
biological, step, adoptive
or foster parent;
or legal guardian
NOTE: Upon our receipt of your approved documentation, coverage for your new dependents will begin on the later of
the commencement of your eligibility or the date your dependents become eligible.
I have read and understand the rules for new dependents.
Participant signature