Form Cef14 - Contractual / Variable Hour Employees Health Benefits Enrollment And Change Form For January-December 2015 Page 2

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ENROLLMENT FOR JANUARY 2015-DECEMBER 2015

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

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:

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

• Grandchildren and Legal Wards age 25 are not eligible for tax-favored coverage and you may owe increased taxes if the State subsidizes dependent coverage for individuals

who are not your tax dependents. Refer to the Benefits Guide for details.