List the names of each eligible dependents to be covered(Spouse and children up to age 26).
Dependent #1
I ACCEPT
By selecting the “I Accept” button, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
The undersigned represents and warrants that he/she has been authorized to execute this subscriber application and make the foregoing certifications on behalf of the employer, has been provided a copy and has read, understands and agrees to the conditions listed here.
