L.E.E.B.A. Benefit Enrollment Information Sheet

All information is held confidential. This information is required and used for enrollment purposes only and will not be disclosed to any third party.

Member/Union

DEPDOTSEA

Current Status

Active Retired

Benefit Action

Add Enrollment Qualifying Event Change Terminate Enrollmen

Name

Address

Apt, Suite, etc.

City

State

ZIP

Date of Birth

Phone

Gender

Alternate Phone

Alternate Email

Department

Agency

Employee #

Date Hired

Command

Rank

PPOHDMO

Member Spouse's Name

Gender

Date of Birthday

Dependent #2 Name

Gender

Date of Birth

Dependent #3 Name

Gender

Date of Birth

Dependent #4 Name

Gender

Date of Birth

Signature