First Name, Middle Initial, Last Name:
These fields should be used to input the member's name. The First and Last Name fields are required to add coverage.
Example: John L Smith Jr

Social Security Number:
The member's social security number should be entered without dashes.
Example: 000112222

Division:
If multiple Divisions exist for your policy, select the appropriate Division for the member that you are adding coverage for.

Class:
Select the appropriate Class for the member you are adding or changing coverage for.

Department:
If Departments exist for your policy, select the appropriate Department for the member that you are adding coverage for.

Gender:
Select the Gender of the member you are adding coverage for.

Date of Birth:
Enter the Date of Birth of the member you are adding coverage for.
Example: 12/01/1950

Full Time Date of Hire:
Enter the date the member became of Full Time status.
Example: 04/15/2001

Rehire Date:
Enter a Rehire Date if the member previously held coverage under your current plan, terminated coverage because of termination of employment, and has now been rehired.
Example: 04/15/2001

Occupation:
The member's current occupation should be input here.

Hours Worked:
Input the total number of hours the member works each week.
Example: 40

Earning Paid:
Select Hourly or Salaried for the method the member's earnings are paid.

Address:
Enter the member's home address.

City:
Enter the City the member's home address is located in.

State:
Enter the member's home address State.

Zip:
Enter the member's home address zip code.
Example: 55555-2222

Coverage Type:
Select the level of dependent coverage the member is electing.

Date enrollment form signed:
Enter the date the member signed the Enrollment/Change form.