DENTAL TRANSACTION FORM 
                Orange County Self-Insured
                  *****OPTION TRANSFER 2011*****    
Last Name                                                  First Name                                      MI

Street Address 
Social Security Number










City                                                                         State                    Zip Code


 Date of Birth



Marital Status: ? Single   ? Married   ? Widowed   ? Divorced
 Date of Marriage



?   Decline Coverage
Date of Hire



?   Request Enrollment � Individual
?   Request Enrollment � Family   Complete Dependent Information

?    Change Name � Previous Name Was:

?    Change To Individual - Reason:
Date:
?    Change To Family -  Reason:
Date:
?    Add a dependent -  Reason:
Date:
?    Remove a dependent -  Reason:  
Date:

List Name of Dependent(s) to be Added or Removed
Last Name 
First Name
Date of Birth
Relationship
Social Security No.






























Note: Relationship: Sp-Spouse,  Dtr-Daughter,  Son-Son,  S/Son-Stepson,  S/Dtr-Stepdaughter,  L/G-Legal Guardianship

 Is your spouse employed by Orange County OR Orange County Community College  YES _______   NO_______

YOU MUST PROVIDE PROOF for all dependents being added to your coverage for the first time: copy of government issued marriage certificate if adding spouse, birth certificate(s), social security card(s), legal guardianship papers, etc. Remove dependents as soon as they are no longer eligible; you must remove ex- spouse as soon as divorce is final. Copy of the divorce decree (first and last page) and ex- spouse�s most recent address are required. 
    
I understand that if I am required to make contributions as a result of this request, my employee contributions for the benefit will be taken on a pre-tax basis (IRS Section 125) unless I notify Risk Management, in writing, to the contrary.  

SIGNATURE: 								   DATE: _________________

For Risk Use Only:
Group No.
Dept No.
Effective Date
Documents on File
125 Status Chg Form





Risk Management Division � Health Benefits Unit � 615-3600                                                             Revised 9/07