Employee Benefit Dependent Addition Request
Employee Information
Employee Name
Employee ID
Department
Email
Phone
Dependent Information
Dependent Name
Relationship
Spouse
Child
Other
Date of Birth
SSN
Gender
Male
Female
Other
Prefer not to say
Benefit Coverage Election
Medical Coverage
Add
Decline
Dental Coverage
Add
Decline
Vision Coverage
Add
Decline
Additional Information
Comments / Notes
Employee Signature
Date