Combined Insurance Enrollment Form - City Of Toppenish Page 2
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4Dependents
Please list all dependents that should be covered on your insurance. Leaving them off the form will terminate
coverage. Proof of dependency may be requested, but not limited to, birth certificate, adoption papers. Medical, Dental & Vision:
A dependent is a child, stepchild or adopted child; less than age 26 or prior to age 26 was incapable of self-support due to developmental disabilities or physical
handicap (proof of incapacity required). Life: A dependent is a child, stepchild or adopted child from birth but less than age 26.
Dependent #1_____
Dependent #2_____
Please check all appropriate boxes and fill in the appropriate blanks.
Please check all appropriate boxes and fill in the appropriate blanks.
For addi-tional dependents, please fill out additional forms and alter
For addi-tional dependents, please fill out additional forms and alter
“Dependent #____.”
“Dependent #____.”
Name (last, first, middle initial)
Name (last, first, middle initial)
SSN
SSN
Gender Date of birth
Relationship to insured
Gender Date of birth
Relationship to insured
Type of insurance requested: ❏ Medical ❏ Dental ❏ Vision ❏ Life
Type of insurance requested: ❏ Medical ❏ Dental ❏ Vision ❏ Life
Is dependent covered by any other insurance now or in the past
Is dependent covered by any other insurance now or in the past
three months? ❏ Yes ❏ No
three months? ❏ Yes ❏ No
If yes, name of other insurance company & type (medical, dental, etc.)
If yes, name of other insurance company & type (medical, dental, etc.)
Name of insured (last, first, intial)
SSN of insured
Name of insured (last, first, intial)
SSN of insured
Group/policy #
Effective date
Termination date
Group/policy #
Effective date
Termination date
Does he/she live with you? ❏ Yes ❏ No
Does he/she live with you? ❏ Yes ❏ No
If no, name of person with whom he/she resides
If no, name of person with whom he/she resides
Last, first, intitial
SSN
Last, first, intitial
SSN
Home address
Home phone
Home address
Home phone
City
State
Zip
City
State
Zip
If divorced, do you have custody? ❏ Yes ❏ No
If divorced, do you have custody? ❏ Yes ❏ No
If no, name of person with custody (last, first, intial) SSN
If no, name of person with custody (last, first, intial) SSN
Home address
Home phone
Home address
Home phone
City
State
Zip
City
State
Zip
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Parent category: Legal