ORANGE COUNTY SELF-FUNDED
DENTAL I VISION
ENROLLMENT FORM


COVERAGE INDIVIDUAL FAMILY NONE 
DENTAL 
VISION 
LAST NAME FIRST NAME SOCIAL SECURITY NUMBER 
ADDRESS 
DATE OF BIRTH DATE OF HIRE 
Dependent Information 
Last Name 
(If Different) 
First Name Date of Birth .Relationship Social Security No 

Risk Management Division / Health Benefits Unit � 291-2139 

Reminder: Student Certification MUST be on file for each dependent listed above who is between the ages of 
19 and 25 

EMPLOYEE SIGNATURE: _______________________________ DATE: ___________ 
For Risk Use Only:Effective Date: _____________________________ 

Group Number: 
Payroll Of: 
Comments: