Spouse or eligible You may disenroll You must submit Coverage ends on the last day of dependent(s) enrolls in an yourself, spouse, or documentation of the month in which the event takes employer group plan dependent(s) who enrollment in the place. during the open enroll in a enrollment period that plan of the plan. operates on a plan year same type (e.g., other than a calendar year medical, dental, vision). Other: Refer to Section 3 (Eligibility) and Section 4 (Mid-Year Enrollment/Disenrollment Events) in the for a complete list of qualifying events and supporting documentation requirements. Dependent Information: Please list each family member below that you wish to DISENROLL Relationship Birth First Name Last Name M.I. SSN Gender Medical Dental Vision to Employee Date D. Employee Certification and Signature Authorize Elections
Spouse or eligible dependent(s) enrolls in an employer group plan during the open enrollment period that operates on a plan year other than a calendar year You may disenroll yourself, spouse, or dependent(s) who enroll in a plan of the same type (e.g., medical, dental, vision). You must submit documentation of enrollment in the plan. Coverage ends on the last day of the month in which the event takes place. Other: Refer to Section 3 (Eligibility) and Section 4 (Mid-Year Enrollment/Disenrollment Events) in the for a complete list of qualifying events and supporting documentation requirements. Dependent Information: Please list each family member below that you wish to DISENROLL First Name Last Name M.I. Relationship to Employee SSN Gender Birth Date Medical Dental Vision D. Employee Certification and Signature Authorize Elections
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