Enrollment/change Form Page 2
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2FAMILY INFORMATION
Dependents to be enrolled, cancelled, changed: (Attach additional sheet if necessary)
First Name
MI
Last Name
Check
(if different)
Appropriate
Date of Birth
Sex
Relationship**
Incapacitated***
Box
Dependent Social Security Number or Assigned ID
Enroll
M
Spouse
Change
____/____/______
F
Domestic Partner*
Not Applicable
SS# ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Cancel
Enroll
M
Change
____/____/______
Dependent
Yes
No
F
SS# ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Cancel
Enroll
M
Change
____/____/______
Dependent
Yes
No
F
SS# ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Cancel
Enroll
M
Change
____/____/______
Dependent
Yes
No
F
SS# ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Cancel
Enroll
M
Change
____/____/______
Dependent
Yes
No
F
SS# ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Cancel
*A Domestic Partnership is established when both persons have filed a Declaration of Domestic Partnership with the State of California.
**For court ordered Dependent(s), legal documentation must be attached. Please see an Employer representative for more information about the
qualifications for full-time student status. If Dependent(s) does not reside with enrollee, please provide address on separate sheet.
*** Dependent is unmarried, financially dependent upon subscriber/covered person and is mentally or physically disabled. If answered “Yes” for
Incapacitated, please attach medical certification of disability.
AUTHORIZATION AND ACKNOWLEDGEMENT
(form must be signed)
I hereby declare that all the statements made above are, to the best of my knowledge and belief, true and complete and that they are the basis on
which insurance requested by me may be issued.
All statements made by me are: representations; and, not warranties. No statement made by me will be used to: contest the insurance provided by the
Policy, unless, it is contained in a written statement signed by me; and, a copy of the statement is furnished to me or my beneficiary.
I understand that by signing this form I am authorizing the necessary premium deductions from my salary or wages for the coverage(s) I have selected.
I acknowledge that I have read the applicable Fraud Warning Notices provided below.
FRAUD WARNING NOTICE:
For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the
payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Employee/Enrollee Signature:
Date: _____/_____/________
SPECALL-ENROLL-ER-CA (08/2012)
Page 2
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Parent category: Medical