9 / 13
2015 Benefits Guide
8
ENROLLMENT WORKSHEET-
(for employee use only)
DEPENDENT PARTICIPATION DETAIL
Legal Name
SS#
Relationship Gender
DOB
Medical
Yes or
No
Dental
Yes or
No
Vision
Yes or
No
Basic Life Primary Beneficiary(s) - Total Must Equal 100%
Name
SS#
Relationship
%
Name
SS#
Relationship
%
Basic Life Contingent Beneficiary(s) - Total Must Equal 100%
Name
SS#
Relationship
%
Name
SS#
Relationship
%
Voluntary Life Primary Beneficiary(s) - Total Must Equal 100%
Name
SS#
Relationship
%
Name
SS#
Relationship
%
Voluntary Life Contingent Beneficiary(s) - Total Must Equal 100%
Name
SS#
Relationship
%
Name
SS#
Relationship
%
BENEFICIARY INFORMATION