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SECTION I – EMPLOYEE INFORMATION AND COVERAGE ELECTION

Employer Name DUBUQUE COUNTY Group # 2202 Division Plan

Name (First, MI, Last) Social Security #_____. Hire Date ____/____/____

Street Address Telephone Effective Date ____/____/____

City State Zip Date of Birth ____/____/____ Email address

☐ Male ☐ Female Marital Status ☐ Married ☐ Single ☐ Divorced ☐ Legally Separated ☐ Widow/Widower

Reason for Completing this Form

• Spouse ❑ Spouse (lawful) ❑

Medical & Vision ☐ Single ☐ Family ☐ Decline ☐ New Hire ☐ Late Enrollment ☐ Marriage/Birth/Adoption ☐ Terminate Coverage for one/all dependents ☐ List dependents who are no longer covered ☐ Part/Full-time Change ☐ Special Enrollment/Loss of Coverage Date Coverage lost _____ ☐ Voluntary or ☐ Lost other coverage Date of Event/Change ____/____/____

• ❑ Step Child ❑

SECTION II – ELIGIBLE DEPENDENTS INFORMATION Note: This application does not guarantee coverage.

• ❑ Step Child ❑

Name (First, MI, Last) Relationship Social Security #-(SSN) Federal law MMSEA requires collection of SSN for all dependents Date Of Birth Gender

• ❑ Step Child ❑

Spouse ☐ Spouse (lawful) ☐ Other ☐ M ☐ F

• ❑ Step Child ❑

for all dependents

Dependent ☐ Natural/Adopted ☐ Step Child ☐ Foster Child ☐ Other ☐ M ☐ F

Dependent ☐ Natural/Adopted ☐ Step Child ☐ Other ☐ M ☐ F

Dependent ☐ Natural/Adopted ☐ Step Child ☐ Foster Child ☐ Other ☐ M ☐ F

Dependent ☐ Natural/Adopted ☐ Step Child ☐ Other ☐ M ☐ F

SECTION III – OTHER COVERAGE Note: This section must be completed for SISCO to process your dependent claims.

PART A: Spouse (if applicable) Date of Marriage PART B: Ex-spouse (if applicable) Divorce Date

Name & City of Employer (this information is for Coordination of Benefits for any dependent children) Ex-Spouse Name(s) _____ Address(es) _____ Social Security # (if available) _____ Name and City of Employer(s) _____ If your ex-spouse has coverage through this employer, _____ 1. Indicate the type of coverage: ☐ Medical ☐ Dental ☐ Prescription Drug ☐ Vision 2. What date did this coverage become effective? _____ 3. List the children covered under this plan _____ 4. List the children covered under this plan _____ 5. List the children covered under this plan _____ 6. List the children covered under this plan _____ 7. List the children covered under this plan _____ 8. List the children covered under this plan _____ 9. List the children covered under this plan _____ 10. List the children covered under this plan _____ 11. List the children covered under this plan _____ 12. List the children covered under this plan _____ 13. List the children covered under this plan _____ 14. List the children covered under this plan _____ 15. List the children covered under this plan _____ 16. List the children covered under this plan _____ 17. List the children covered under this plan _____ 18. List the children covered under this plan _____ 19. List the children covered under this plan _____ 20. List the children covered under this plan _____ 21. List the children covered under this plan _____ 22. List the children covered under this plan _____ 23. List the children covered under this plan _____ 24. List the children covered under this plan _____ 25. List the children covered under this plan _____ 26. List the children covered under this plan _____ 27. List the children covered under this plan _____ 28. List the children covered under this plan _____ 29. List the children covered under this plan _____ 30. List the children covered under this plan _____ 31. List the children covered under this plan _____ 32. List the children covered under this plan _____ 33. List the children covered under this plan _____ 34. List the children covered under this plan _____ 35. List the children covered under this plan _____ 36. List the children covered under this plan _____ 37. List the children covered under this plan _____ 38. List the children covered under this plan _____ 39. List the children covered under this plan _____ 40. List the children covered under this plan _____ 41. List the children covered under this plan _____ 42. List the children covered under this plan _____ 43. List the children covered under this plan _____ 44. List the children covered under this plan _____ 45. List the children covered under this plan _____ 46. List the children covered under this plan _____ 47. List the children covered under this plan _____ 48. List the children covered under this plan _____ 49. List the children covered under this plan _____ 50. List the children covered under this plan _____ 51. List the children covered under this plan _____ 52. List the children covered under this plan _____ 53. List the children covered under this plan _____ 54. List the children covered under this plan _____ 55. List the children covered under this plan _____ 56. List the children covered under this plan _____ 57. List the children covered under this plan _____ 58. List the children covered under this plan _____ 59. List the children covered under this plan _____ 60. List the children covered under this plan _____ 61. List the children covered under this plan _____ 62. List the children covered under this plan _____ 63. List the children covered under this plan _____ 64. List the children covered under this plan _____ 65. List the children covered under this plan _____ 66. List the children covered under this plan _____ 67. List the children covered under this plan _____ 68. List the children covered under this plan _____ 69. List the children covered under this plan _____ 70. List the children covered under this plan _____ 71. List the children covered under this plan _____ 72. List the children covered under this plan _____ 73. List the children covered under this plan _____ 74. List the children covered under this plan _____ 75. List the children covered under this plan _____ 76. List the children covered under this plan _____ 77. List the children covered under this plan _____ 78. List the children covered under this plan _____ 79. List the children covered under this plan _____ 80. List the children covered under this plan _____ 81. List the children covered under this plan _____ 82. List the children covered under this plan _____ 83. List the children covered under this plan _____ 84. List the children covered under this plan _____ 85. List the children covered under this plan _____ 86. List the children covered under this plan _____ 87. List the children covered under this plan _____ 88. List the children covered under this plan _____ 89. List the children covered under this plan _____ 90. 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List the children covered under this plan _____ 110. List the children covered under this plan _____ 111. List the children covered under this plan _____ 112. List the children covered under this plan _____ 113. List the children covered under this plan _____ 114. List the children covered under this plan _____ 115. List the children covered under this plan _____ 116. List the children covered under this plan _____ 117. List the children covered under this plan _____ 118. List the children covered under this plan _____ 119. List the children covered under this plan _____ 200. List the children covered under this plan _____ 201. List the children covered under this plan _____ 202. List the children covered under this plan _____ 203. List the children covered under this plan _____ 204. List the children covered under this plan _____ 205. List the children covered under this plan _____ 206. List the children covered under this plan _____ 207. List the children covered under this plan _____ 208. List the children covered under this plan _____ 209. List the children covered under this plan _____ 300. List the children covered under this plan _____ 301. List the children covered under this plan _____ 302. List the children covered under this plan _____ 303. List the children covered under this plan _____ 304. List the children covered under this plan _____ 305. List the children covered under this plan _____ 306. List the children covered under this plan _____ 307. List the children covered under this plan _____ 308. List the children covered under this plan _____ 309. List the children covered under this plan _____ 400. List the children covered under this plan _____ 401. List the children covered under this plan _____ 402. List the children covered under this plan _____ 403. List the children covered under this plan _____ 404. List the children covered under this plan _____ 405. List the children covered under this plan _____ 406. List the children covered under this plan _____ 407. List the children covered under this plan _____ 408. List the children covered under this plan _____ 409. List the children covered under this plan _____ 500. List the children covered under this plan _____ 501. List the children covered under this plan _____ 502. List the children covered under this plan _____ 503. List the children covered under this plan _____ 504. List the children covered under this plan _____ 505. List the children covered under this plan _____ 506. List the children covered under this plan _____ 507. List the children covered under this plan _____ 508. List the children covered under this plan _____ 509. List the children covered under this plan _____ 600. List the children covered under this plan _____ 601. List the children covered under this plan _____ 602. List the children covered under this plan _____ 603. List the children covered under this plan _____ 604. List the children covered under this plan _____ 605. List the children covered under this plan _____ 606. List the children covered under this plan _____ 607. List the children covered under this plan _____ 608. List the children covered under this plan _____ 609. List the children covered under this plan _____ 700. List the children covered under this plan _____ 701. List the children covered under this plan _____ 702. List the children covered under this plan _____ 703. List the children covered under this plan _____ 704. List the children covered under this plan _____ 705. List the children covered under this plan _____ 706. List the children covered under this plan _____ 707. List the children covered under this plan _____ 708. List the children covered under this plan _____ 709. List the children covered under this plan _____ 800. List the children covered under this plan _____ 801. List the children covered under this plan _____ 802. List the children covered under this plan _____ 803. List the children covered under this plan _____ 804. List the children covered under this plan _____ 805. List the children covered under this plan _____ 806. List the children covered under this plan _____ 807. List the children covered under this plan _____ 808. List the children covered under this plan _____ 809. List the children covered under this plan _____ 900. List the children covered under this plan _____ 901. List the children covered under this plan _____ 902. List the children covered under this plan _____ 903. List the children covered under this plan _____ 904. List the children covered under this plan _____ 905. List the children covered under this plan _____ 906. List the children covered under this plan _____ 907. List the children covered under this plan _____ 908. List the children covered under this plan _____ 909. List the children covered under this plan _____ 1000. List the children covered under this plan _____ 1001. List the children covered under this plan _____ 1002. List the children covered under this plan _____ 1003. List the children covered under this plan _____ 1004. List the children covered under this plan _____ 1005. List the children covered under this plan _____ 1006. List the children covered under this plan _____ 1007. List the children covered under this plan _____ 1008. List the children covered under this plan _____ 1009. List the children covered under this plan _____ 1010. List the children covered under this plan _____ 1011. List the children covered under this plan _____ 1012. List the children covered under this plan _____ 1013. List the children covered under this plan _____ 1014. List the children covered under this plan _____ 1015. List the children covered under this plan _____ 1016. List the children covered under this plan _____ 1017. List the children covered under this plan _____ 1018. List the children covered under this plan _____ 1019. List the children covered under this plan _____ 1020. List the children covered under this plan _____ 1021. List the children covered under this plan _____ 1022. List the children covered under this plan _____ 1023. List the children covered under this plan _____ 1024. List the children covered under this plan _____ 1025. List the children covered under this plan _____ 1026. List the children covered under this plan _____ 1027. List the children covered under this plan _____ 1028. List the children covered under this plan _____ 1029. List the children covered under this plan _____ 1030. List the children covered under this plan _____ 1031. List the children covered under this plan _____ 1032. List the children covered under this plan _____ 1033. List the children covered under this plan _____ 1034. List the children covered under this plan _____ 1035. List the children covered under this plan _____ 1036. List the children covered under this plan _____ 1037. List the children covered under this plan _____ 1038. List the children covered under this plan _____ 1039. List the children covered under this plan _____ 1040. List the children covered under this plan _____ 1041. List the children covered under this plan _____ 1042. List the

Enroll 1 Medical/Dental 4 Levels 2010

Self Insured Services Company Phone 800-457-4726 Enrollment Department Ext. 5420