DEPENDENT INFORMATION This mustbe completedifyou areadding a spouse or childrentothe DENTAL or VISION plan. Spouse ___________________________ DOB ____/____/_______ SS# _______-______-__________ Gender M or F Child ______________________________ DOB ___/____/_______ SS# _______-______-__________ Gender M or F Child ______________________________ DOB ___/____/_______ SS# _______-______-__________ Gender M or F Child ______________________________ DOB ___/____/_______ SS# _______-______-__________ Gender M or F Child ______________________________ DOB ___/____/_______ SS# _______-______-__________ Gender M or F Child ______________________________ DOB ___/____/_______ SS# _______-______-__________ Gender M or F SIGNATURE • I understand the elections I have chosen. I acknowledge that the group’s SummaryPlan Description and Annual Notices are available in the HR Departmentfor my review if needed. • I affirm that I can only make changes to my elections during a qualifying event or during annual open enrollment, ending before June 1, 2022. ___________________________________________ Signature Date