Application
Complete, sign and date the Application/Change Form. Be sure to check the box for the medical and dental plan being selected. For dependents under age 18, the application must have a parent/guardian’s signature and date, and the parent/guardian’s full name must be printed on the application. Dependents age 18 and over must sign and date the application themselves. Submit other documentation: Domestic Partner Verification Form or Disabled Dependent Form, if applicable.
