Form Asef15 - Active & Satellite Employeeshealth 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

NUMBER AND DATE OF BIRTH) TO ENSURE YOUR DEPENDENTS ARE ENROLLED IN THE PLANS YOU SELECT. Please use this section for additions (A),

deletions (D) or changes (C) to your existing dependent information for Open Enrollment or a qualifying event.

DATE OF

(P)

COVER THIS DEPENDENT FOR:

LAST NAME

FIRST NAME, MI

SEX

BIRTH

RELATIONSHIP

SOCIAL SECURITY NO.

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.