Voluntary Plan Information

Enrollment and Change Form New Applicant or Change Applicant: Cobra Eff. Date:
Plan Holder Name (Company Name):	Division:	Sex:		Effective Date:
Planholder Street Address:	Hire Date:
Employees Name (Last, First, MI): Salutation:			Birthdate:	SSN#:
Employee's Address: Line 1: Line 2: Line 3:	addr. continued... City: State: Zip Code:	Home Phone: Coverage Requested: Single/Family:
Marital Status:
Give the following information for each dependent to be insured: Name (Last, First, MI)	Relationship	Sex	Birth Date	Full-Time Student
1.			(mm/dd/yyyy)
2.			(mm/dd/yyyy)
3.			(mm/dd/yyyy)
4.			(mm/dd/yyyy)
5.			(mm/dd/yyyy)
6.			(mm/dd/yyyy)
Are any dependent children adopted? If "Yes", indicate name and date of adoption: Name:
Have you included step-children as dependents? If "Yes", indicate name is: Name:
Do your step-children reside with you? Are they dependent on you for support and maintenance?
Signature Date:

The Dental Shop has expanded to ProBenefits Administrators, now offering life, vision and disability plans in addition to dental plans.

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