ORANGE COUNTY SELF-INSURED 
DENTAL / VISION 

CHANGE FORM 

o DENTAL o To Family o To Individual o Cancel Coverage 
o VISION o To Family o To Individual o Cancel Coverage 
Last Name First Name MI. Social Security Number 
Street Address 
City State Zip Code 
o Change Name � Previous Name Was: 
(List Dependent Below) 
o Add a dependent Reason: 
(List Dependent to be Removed Below) 
o Remove a dependent Reason: 
Dependent Information 
Last Name First Name Date of Birth Relationship Social Security No. 
Mark 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, you must 
submit a copy of a government issued marriage certificate if adding spouse, birth certificates, Social Security cards, 
legal guardianship papers, and other documents as may be required. To remove a spouse as a result of a divorce, you 
MUST PROVIDE a copy of the divorce decree (first and last page) and ex-spouse�s most recent address. 

I understand that if I am required to make contributions as a result of this change, my employee contributions for the 
benefit(s) will be taken on a pre-tax basis (IRS Section 125) unless I notify Risk Management, in writing, to the contrary. 

SIGNATURE: DATE: _________________ 

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For Risk Use Only: 

Group No. Department No. Effective Date Documents On File 125 Status Chg Form 

Risk Management Division � Health Benefits Unit � 291-2139 Revised 09/02/03