Field
Definition
Req.
First Name
Enter/change the first name of the dependent. You can enter up to 14 alphanumeric characters.
Y
Last Name
Enter/change the last name of the dependent. You can enter up to 14 alphanumeric characters.
Y
Birth Date
Click the Calendar
button 
to select the date the dependent was
born; or type the date in MMDDYYYY format.
You can click the Month
drop down to change the calendar month; and click the Year
drop down to change the calendar year. Click the Right
Arrow button 
to move the calendar forward; click the Left
Arrow button 
to move the calendar backward.
Y
Relationship
Click the Drop Down List
button 
to select the relationship type that describes the dependent's
relationship to you, e.g., spouse, son, daughter, etc.
Y
Gender
Click the Drop Down List
button to select the
dependent's gender.
Y
SSN
Enter/change the dependent's social security number with punctuation (i.e., 123456789).
N
Address 1
Enter/change the first line of the dependent's primary mailing address. You can enter up to 40 alphanumeric characters.
N
Address 2
Enter/change the second line of the dependent's primary mailing address. You can enter up to 40 alphanumeric characters.
N
City
Enter/change the city where the dependent's primary mailing address is located. You can enter up to 40 alphanumeric characters
N
State
Click the Drop Down List
button to select the
state where the dependent's primary mailing address is located.
N
Zip Code
Enter/change the zip code associated with the dependent's primary mailing address. You can enter a 5-digit zip code or the Zip + 4 without punctuation (i.e., 999994444).
N
Phone
Enter/change the dependent's telephone number without any punctuation, i.e., 1234567890.
N
Coverage Start Date
Enter/change the date on which the dependent's current insurance coverage will begin.
N
Coverage End Date
Enter/change the date on which the dependent's current insurance coverage will end.
N
Comments
Enter comments to the approver about this request. You can enter a maximum of 246 characters.
N