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:
JR
SR
II
III
IV
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:
Spouse
Domestic Partner
Child
Reason For Adding Dependent:
Marriage
Birth
Adoption
Loss Of Coverage
Open Enrollment
Effective Date (mm dd yyyy):
Birthdate (mm dd yyyy):
Gender:
Male
Female
Student 19 and Over*:
No
Yes
Is disabled*:
No
Yes
* Annual documentation of student status and/ or disability status will be required.
For questions or comments please contact Kati MacDonald at (617) 948-4265 or kmacdonald@uua.org
