Dental/Vision Insurance Coverage
Please enter your information to enroll/dis-enroll or make changes on your current coverage with TIC's benefit plan for Dental and/or Vision with United States Federation of Worker Co-ops. If you are not currently utilizing the benefit but want to sign up, make sure you select the plan you want. If you do not want the benefit, select "Waive". If you are CURRENTLY enrolled and "Waive" is showing, you will be REMOVED from the insurance.
Name
First Name
Last Name
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Change
Cancel ALL Dental/Vision coverage
NEW Dental and/or Vision coverage
Change Dental Enrollment
Change Vision Enrollment
Dental Insurance
USFWC Dental Plan
WAIVE Dental Insurance
Vision Insurance
USFWC Vision Plan - EyeMed
WAIVE Vision Insurance
Dependents to ADD
Spouse/Partner
Dependent 1
Dependent 2
Dependent 3
Spouse/Partner Name
First Name
Last Name
Spouse/Partner Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Dependent 1 Name
First Name
Last Name
Dependent 1 Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Dependent 2 Name
First Name
Last Name
Dependent 2 Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Dependent 3 Name
First Name
Last Name
Dependent 3 Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Notes/questions:
Signature
Continue
Continue
Should be Empty: