GROUP # B550 CODE CHANGE __________ > ___________
EFFECTIVE DATE: _____________________
 
Please print, fill out completely as possible, and fax or mail.
 
Cypress-Fairbanks I.S.D. Change Form

FORTIS BENEFITS INSURANCE CO.
DENTAL (Indemnity) Plan
Freedom to Choose Any Dentist
   

Employee Name:_____________________

 Soc. Sec. No.: _______-_______-_________
Last First MI
Employee # : ______________________
 Campus/Building Assignment:___________________
Occupation: _______________________ Sex: ___M ___F Date of Birth: ____/ ____ /____
       
INDICATE CHANGE TO BE MADE BELOW
 
[ ] Name Change: ______________________> Changed to > ________________________
Prior Last Name
 New Last Name
[ ] Address Change: ________________________________________
                            ________________________________________
                            ________________________________________
                            ________________________________________
[ ] Telephone: _____________________________________________
___ Cancel All Coverage
 ___ Add Dependents listed below
 ___Cancel Dependents listed below
       
List of Dependents (List ONLY those dependents affected by this change)
Name
 Relationship
 Sex
 Social Security Number Date of Birth
Spouse
_______________________
_______________________
_______________________
_______________________
_______________________
________
________
________
________
________
 M / F
M / F
M / F
M / F
M / F
 ____-____-____
____-____-____
____-____-____
____-____-____
____-____-____
 ______/_____/________
______/_____/________
______/_____/________
______/_____/________
______/_____/________
Change because of :
[ ] Annual Enrollment Date ____________ [ ] Death Date _____________
[ ] Marriage* Date ____________ [ ] Age Ineligibilty Date _____________
[ ] Birth or Adoption*
 Date ____________
 [ ] Job Change
 Date _____________
[ ] Divorce *
 Date ____________
 [ ] Other
 Date _____________
[ ] Job Termination * Date ____________ ___________________________________
       
* Written documentation of this "Change of Family Status" will be required.
       
_________________________________________________
 ____________________________
Employee's Signature
 Date