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DCUE Dental Reimbursement Fund
2015-2016 ENROLLMENT FORM
Please use this form to enroll yourself and your eligible dependents in the DCUE Dental Reimbursement Fund. Eligible dependents
include your spouse, natural and step children, adopted and foster children, to age 26.
Employee Information:
Employee ID
Number
Seniority Date/Original Hire Date:
Last Name
First
MI
Mo
Birth Date
Day
Year
Sex
M/F
Employee
#1
Employee #2: Complete ONLY IF:
Seniority Dt/Original Hire Dt:
Both are ISD #196 employees AND eligible for coverage in the ISD #196 DCUE collective bargaining unit; otherwise, complete Spouse below.
Employee
#2
Address
Street
City
Zip
State
Preferred Phone
Email Address (optional)
Spouse / Dependent Information:
Dependents
Last Name
First
MI
Mo
Birth Date
Day
Year
Sex
M/F
Spouse
Other Dependents
My signature constitutes a request for participation in the DCUE Dental Reimbursement Fund. My signature certifies that
all information provided is true and accurate. Omission of information or provision of false information may result in
forfeiture of my eligibility for myself and any dependents enrolled in the Fund.
Signature #1: ______________________________
Date: ____________________
7373 West 147th Street #107, Apple Valley, MN 55124
Signature #2: ______________________________
Date: ____________________
Phone: 952-432-4033
Email: [email protected]