Federal Dentalblue Enrollment Form Page 2

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For Service Benefi t Plan Basic or Standard Option Enrollees Only
To enroll in Alabama Federal DentalBlue you must reside in the service area of Blue Cross and Blue Shield of Alabama. If you enroll
in the FEHB Basic Option, you will automatically be enrolled in Alabama Federal DentalBlue Basic Option. The same is true for
Standard Option.
If you are a new Standard or Basic Option subscriber, please include a copy of your SF 2809 Form.
Application For Enrollment
EMPLOYEE INFORMATION
PLEASE PRINT USING UPPERCASE LETTERS: USE BLACK BALL POINT PEN - PRESS FIRMLY) * INDICATES REQUIRED FIELDS
DR.
MR.
MRS.
MS.
LAST NAME*
FIRST NAME*
MAIDEN/MIDDLE NAME
SUFFIX (JUNIOR, SENIOR)
SOCIAL SECURITY NUMBER*
MAILING ADDRESS*
CITY*
STATE*
ZIP*
E-MAIL ADDRESS (Optional)
PHONE NUMBER
HOME
WORK
CELL
DATE OF BIRTH (MM/DD/YYYY)*
MALE
FEMALE
FEP ID NUMBER
Please check the appropriate
R
104
Standard Self Only
111 Basic Self Only
FEP Enrollment Code
105
Standard Self and Family
112 Basic Self and Family
Check here if you are electing
DATE OF COVERAGE TERMINATED (MM/DD/YYYY)*
Check here if you are returning to
DATE OF RETURN EMPLOYMENT (MM/DD/YYYY)*
coverage due to termination
full-time civilian employment from
of existing coverage
active military duty.
Check here if you are transferring
DATE OF TRANSFER IN FROM YOUR 2810 Form (MM/DD/YYYY)*
in to Alabama from another state
within the same federal agency.
COVERED DEPENDENTS
List your spouse and/or dependent children below. Only the dependents enrolled under your Service Benefi t Plan coverage are
eligible to enroll in Alabama Federal DentalBlue.
LAST NAME*
FIRST NAME*
MAIDEN/MIDDLE NAME
SUFFIX (JUNIOR, SENIOR)
SOCIAL SECURITY NUMBER*
DATE OF BIRTH (MM/DD/YYYY)*
RELATIONSHIP
GENDER
SPOUSE
OTHER_________________________________
MALE
FEMALE
LAST NAME*
FIRST NAME*
SUFFIX (JUNIOR, SENIOR)
MIDDLE NAME
SOCIAL SECURITY NUMBER*
RELATIONSHIP
GENDER
DATE OF BIRTH (MM/DD/YYYY)*
CHILD
OTHER_________________________________
MALE
FEMALE
BLUE CROSS AND BLUE SHIELD COPY
APPLICANT COPY
ENR-442 (Rev. 9-2011)

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