1) Last Name: First Name Middle Initial

2) Home Address:

3) City: State: Zip Code:

4) Date of Birth (mm/dd/yyyy):

5) Home Phone Number: Work Phone Number:

6) Date of Hire:

7) Sex: Male Female

9) E-mail address:

10) Coverage Type: Individual Yourself and another individual Family

If available and you are electing family coverage, list below the names of spouse and unmarried children under 25 years of age.

• Unmarried children ages 19 to 25 are eligible for benefits only if they are fulltime students.
• Unmarried children 19 years of age or older, who are incapable of self-support because of mental of physical disability are covered provided that the disability began before the age of 19.

First Name	Last Name (if different)	Middle Initial	Relationship	Date of Birth (mm/dd/yyyy)	Full-Time Student
1)			Spouse Daughter Son None		Yes No
2)			Spouse Daughter Son None		Yes No
3)			Spouse Daughter Son None		Yes No
4)			Spouse Daughter Son None		Yes No
5)			Spouse Daughter Son None		Yes No
6)			Spouse Daughter Son None		Yes No
7)			Spouse Daughter Son None		Yes No
8)			Spouse Daughter Son None		Yes No
9)			Spouse Daughter Son		Yes No
10)			Spouse Daughter Son		Yes No
11)			Spouse Daughter Son		Yes No
12)			Spouse Daughter Son		Yes No
13)			Spouse Daughter Son		Yes No
14)			Spouse Daughter Son		Yes No
15)			Spouse Daughter Son		Yes No

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Note: Members who defraud or attempt to defraud the NYSUT Group Benefits Plan or who knowingly give false or misleading information are subject to a penalty which may include suspension of eligibility of all Plan benefits. Members are responsible for notifying the Plan Office of any changes in marital and/or dependent status by submitting a Change of Status Card which is available from the Plan office.

I verify that the above information is true and accurate.
Signature: ________________________

Social Security Number: _________________________________