Form Retef15 - Retiree Health Benefits Enrollment And Change Form - 2016 Page 2

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ENROLLMENT FOR JANUARY 2016-DECEMBER 2016

DEPENDENT INFORMATION

PLEASE PRINT

Dependent means your eligible: (a) spouse, or (b) dependent child(ren) (including biological child, adopted child, stepchild, grandchild, step grandchild, other child relative, 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:

• Biological, adopted and step children age 26 and over must have become disabled prior to reaching age 26 in order to be eligible for continued coverage.

• Tax qualified grandchildren, step grandchildren, legal wards and other child relatives age 25 and over must have become disabled prior to reaching age 25 in order to be eligible for

continued coverage.