EMPLOYEE HEALTH & DENTAL FORM

HEALTH & DENTAL ENROLLMENT, POLICY CHANGES & TERMINATION
for determination of employee credits coverage
Your e-mail is required to receive your account balance and other important information
I agree that my email may be used to receive information regarding my benefits plan. This information will not be reused and will be kept confidential
if yes, please submit claims to your spouse's insurance plan first
if yes, then consider dental extra credits
I have reviewed the above information and sign off on the accuracy of adjustment, additions or removal of Health & Dental Benefits