Add dependent - City of Huntington Beach 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by selecting the qualifying event that applies to you. Check one box and enter the corresponding date.
3. For each dependent you wish to add, fill in their name, relationship, date of birth, and social security number (required for spouse only).
4. Indicate which plans you want to add your dependents to by checking the appropriate boxes for Medical, Dental, and Vision.
5. If applicable, provide details for additional dependents by repeating steps 3 and 4.
6. If you have a name change, ensure to attach a copy of your social security card reflecting the new name.
7. Complete any beneficiary changes by checking the relevant boxes and note that forms will be sent through interoffice mail.
8. Finally, sign and date the form at the bottom before submitting it.

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