APPLICABLE HUMAN RESOURCE LAWS BY COMPANY SIZE

SAMPLE NOTICE OF DEPENDENT ADDRESS

Employee Name ___________________________________ Employee # _____________

Department ______________________________________

Dependent Address ________________________________________________________

City ___________________________ State __________________ Zip _____________

Telephone ( ) _______________________________

The above address applies to the dependent(s) listed below. Company X will provide

a physician directory (when applicable, for the appropriate area and provide any

correspondence required. (i.e.; COBRA Notifications; Plan Changes; Benefits Package

and updates)

NAME SOCIAL SECURITY

(This is required information)

________________________________ ______________________________

________________________________ ______________________________

________________________________ ______________________________

________________________________ ______________________________

If the dependent is under the age of 18, please provide the name of adult with whom they reside.

Name __________________________________ Relationship _____________________

Employee Signature _________________________________ Date __________________