Dental and Vision Benefits Enrollment Form
Employee Information
First Name
Last Name
Employee ID
Date of Birth
Email Address
Phone Number
Address
Enrollment Selection
Dental Plan
Employee Only
Employee + Spouse
Employee + Children
Family
Vision Plan
Employee Only
Employee + Spouse
Employee + Children
Family
Dependent Information
Dependent Name
Relationship
Date of Birth
Dependent Name
Relationship
Date of Birth
Additional Comments
Signature
Date