UUA Insurance Enrollment Application

Add a Dependent to Existing Coverage:
Please fill out this form in its entirety for each dependent you wish to add to your coverage.
Employee First Name:
Employee Last Name:
Employee Social Security Number:
Employee Email:

Dependent First Name:
Dependent Last Name:
Middle: Suffix:

Dependent Home Address Same as Employee?
Address Line 1: Apt:
Address Line 2:
City: State: Zip Code:
Home Phone:

Dependent Social Security Number: Pending:
Relation Code:  
Reason For Adding Dependent:  
Effective Date (mm dd yyyy):

Birthdate (mm dd yyyy):
Is disabled*:
* Annual documentation of disability status will be required.

For questions or comments please contact Insurance Plans at (888) 792-7496 or InsurancePlans@uua.org

Unitarian Universalist Association of Congregations | 24 Farnsworth Street | Boston, MA 02210-1409

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