Form Rethlhen03-I - Retiree Health Benefits Enrollment And Change Form - 2014 Page 2

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ENROLLMENT FOR JANUARY 2014-DECEMBER 2014

DEPENDENT INFORMATION

PLEASE PRINT

Dependent means your eligible: (a) spouse, or (b) dependent child(ren) (including biological child, adopted child, stepchild, grandchild, step grandchild, legal ward). See Benefits Guide

for a complete listing of eligible dependents and the dependent documentation requirements.

Please provide your dependent information below. PLEASE PRINT. THIS FORM MUST BE FILLED OUT COMPLETELY INCLUDING SOCIAL SECURITY NUMBERS,

DATE OF BIRTH, AND IF THE DEPENDENT IS ELIGIBLE FOR MEDICARE DUE TO AGE (AGE 65) OR DISABILITY (ANY AGE) TO ENSURE THAT YOUR

DEPENDENTS ARE ENROLLED IN THE PLANS YOU SELECT AND CLAIMS ARE PAID PROPERLY. Please use this section for additions (A), deletions (D) or changes

DATE OF

ELIGIBLE FOR

(P)

COvER ThIS DEPENDENT FOR:

LAST NAME

FIRST NAME, MI

SEx

BIRTh

RELATIONShIP

MEDICARE

SOCIAL SECURITY NO.

(Y/N)

MM/DD/YYYY

MEDICAL

DRUG

DENTAL

Special Notifications:

• Tax-qualified dependent children age 26 and over must be disabled prior to reaching age 26 in order to be eligible for continued coverage.

• Some dependents are not eligible for tax-favored coverage and you may owe increased income taxes if the State subsidizes dependent coverage for individuals who are not your tax

dependents. Refer to the Benefits Guide for details.