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NAME First Middle Last ACTION CODE LIST ALL PERSONS TO BE ENROLLED IN DENTAL PLAN Include self First DATE OF BIRTH FAMILY RELATIONSHIP MM/ DD/ YY GENDER ADDRESS Number and Street City State and Zip SSN 4. EFFECTIVE 15. AGENCY 16. UNIT CODE 17. AGENCY NAME OR RETIREMENT SYSTEM IF RETIRED MONTH DAY YEAR 18 REMARKS PREMIUM AGENCY CALPERS RETIREE 19. SIGNING PERSONNEL OFFICER S NAME Please Print 20. AUTHORIZED AGENCY SIGNATURE I hereby certify under penalty of perjury as follows That I am the duly ...

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