Dental Active Retiree InformationName(Required) First Last Email Address(Required) Enter Email Confirm Email Phone NumberAddress(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth(Required)Social Security Number(Required)Employer Option Steel OPERS OPF OtherThis field is hidden when viewing the formEnrolled in Medicare(Required) Yes No Enrollment DateDental I wish to enroll in the program.This field is hidden when viewing the formEmployer OptionSpouse InformationComplete this section if you are the spouse of a living retiree.Spouse Enrollment I wish to enroll my spouse.Spouse Name First Last Spouse PhoneThis field is hidden when viewing the formAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanàland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Spouse Date of BirthSpouse Social Security NumberThis field is hidden when viewing the formEnrolled in Medicare Yes NoThis field is hidden when viewing the formSpouse Medicare ID#I wish to enroll my spouse in: Dental OnlyDependent(s) InformationComplete this section if you are the dependents of a living retiree.Dependents Enrollment I wish to enroll my dependent child(ren).List of DependentsFirst NameLast NameDate of BirthSexRelationship to RetireeSSN Add RemoveThis field is hidden when viewing the formNumber of DependentsPlease enter a number from 1 to 20.Enter the number of dependents.This field is hidden when viewing the formName First Last This field is hidden when viewing the formGender(Required)MaleFemaleThis field is hidden when viewing the formSSNThis field is hidden when viewing the form DOBBanking Information (Optional)Please provide the bank account that we are authorized to pull payment from.I want to provide bank info for ACH withdrawals. Yes NoBank Account Type(Required)Personal CheckingPersonal SavingsPlease choose the type of bank account we are withdrawing from.Bank Routing Number(Required)Enter your bank’s routing number.Bank Account Number(Required)Enter your bank account number.ConfirmationEntered By First Last If this application was entered in behalf of the applicant, please enter your name.Signature of Applicant(Required)Please enter your full name to sign this form.Consent(Required) By checking this form and providing my signature, I attest that all information is true and accurate to the best of my knowledge.(Required)
