**UCI**

+-----------------------------------+-----------------------------------+
| 4400-ADV (5-2005)                 | ![](media/image1                  |
|                                   | .png){width="2.435416666666667in" |
| Supersedes (4-2005) issue         | height="0.3854166666666667in"}    |
+-----------------------------------+-----------------------------------+

**Application for Sandia's Dental & Vision Plans**

Initial Enrollment Reinstatement from Leave of Absence Additions/Changes

**A) Primary Member Information**

  --------- ------- ------ ----------- ----------- ------- ----------- -------- -- ----------- ----------- -- -------- -- -------- ----------- -----------
  Name                     **     **                                               SSN:        **     **                  Union:   **     **   
  (Last,                                                                                                                                       
  First,                                                                                                                                       
  MI):                                                                                                                                         

  Gender:   ** **   DOB:               **     **   Hire    **     **   Bus.        **     **                  Home                             **     **
                                                   Date:               Phone:                                 Phone:                           
  --------- ------- ------ ----------- ----------- ------- ----------- -------- -- ----------- ----------- -- -------- -- -------- ----------- -----------

**B) Enrollment Information**

  -------------- --------- -------------------------- --------- -------------------------
  **Type of      Dental                               Vision    
  coverage:**                                                   

                           Single                               Single

                           Family\*                             Family\*

                           Decline coverage                     Decline coverage

                           Dependent of another                 Dependent of another
                           Sandian\*\*                          Sandian\*\*
  -------------- --------- -------------------------- --------- -------------------------

+-----------------------------------+---+----------------+---+---+-------+
| \*If you checked Family, please   | N | **     **      |   | S | **    |
| list your dependents below.       | a |                |   | S |    ** |
|                                   | m |                |   | N |       |
| \*\*If you are a dependent under  | e |                |   | : |       |
| another Sandian's dental and/or   | : |                |   |   |       |
|                                   |   |                |   |   |       |
| vision plan(s), please enter      |   |                |   |   |       |
| their name and SSN here:          |   |                |   |   |       |
+-----------------------------------+---+----------------+---+---+-------+

+---------------------+---------+----+--------+---------+------+-----+
| **Dependents to be  |         |    |        |         |      |     |
| insured:**          |         |    |        |         |      |     |
+---------------------+---------+----+--------+---------+------+-----+
| Dependents          |         |    |        |         | FOR  |     |
| eligibility         |         |    |        |         | BENE |     |
| requirements are    |         |    |        |         | FITS |     |
| detailed in the     |         |    |        |         | USE  |     |
| applicable Summary  |         |    |        |         | ONLY |     |
| Plan Descriptions.  |         |    |        |         |      |     |
+---------------------+---------+----+--------+---------+------+-----+
| Dependent(s)        | Relat   | Ge | Birth  | Social  | E    | Can |
| Name(s)             | ionship | nd | Date   | S       | ffec | cel |
|                     | to      | er |        | ecurity | tive | D   |
|                     |         |    |        | \#      | Date | ate |
|                     | Employe |    |        |         |      |     |
|                     | e\*\*\* |    |        |         |      |     |
+---------------------+---------+----+--------+---------+------+-----+
| **     **           | **      | *  | **     | **      |      |     |
|                     |      ** | *  |     ** |      ** |      |     |
|                     |         | ** |        |         |      |     |
+---------------------+---------+----+--------+---------+------+-----+
| **     **           | **      | *  | **     | **      |      |     |
|                     |      ** | *  |     ** |      ** |      |     |
|                     |         | ** |        |         |      |     |
+---------------------+---------+----+--------+---------+------+-----+
| **     **           | **      | *  | **     | **      |      |     |
|                     |      ** | *  |     ** |      ** |      |     |
|                     |         | ** |        |         |      |     |
+---------------------+---------+----+--------+---------+------+-----+
| **     **           | **      | *  | **     | **      |      |     |
|                     |      ** | *  |     ** |      ** |      |     |
|                     |         | ** |        |         |      |     |
+---------------------+---------+----+--------+---------+------+-----+
| **     **           | **      | *  | **     | **      |      |     |
|                     |      ** | *  |     ** |      ** |      |     |
|                     |         | ** |        |         |      |     |
+---------------------+---------+----+--------+---------+------+-----+

  ------------------------- ------------- --------------------------------
  Reason for enrollment                   **     **
  (e.g., new hire,                        
  marriage, new baby, etc.)               

  Dental & Vision coverage  **     **     
  effective date:                         
  ------------------------- ------------- --------------------------------

**C) Sign below to authorize the enrollment of the above dependent(s) in
your dental and/or vision coverage.**

  ------------------------------------ -- ---------- --- ------------------
                                                         

  Employee Signature                      Date           
  ------------------------------------ -- ---------- --- ------------------

+-------------------------------------+--------------------------------+
| **Note:** This form must be         | ***Fax this form to            |
| received by the Benefits Customer   | 505-844-7535 or mail to***:    |
| Service Center within 31 days of    |                                |
| the mid-year election change event  | Sandia National Laboratories   |
| if your premiums are deducted on a  |                                |
| pre-tax basis.                      | Attn: Benefits Customer        |
|                                     | Service                        |
|                                     |                                |
|                                     | PO Box 5800 MS 1022            |
|                                     |                                |
|                                     | Albuquerque, NM 87185-1022     |
+-------------------------------------+--------------------------------+

  ----------------------------------------- --- --------------------------
  *For Benefits Use Only:*                      

                                                **     **

  Signature of Benefits representative          Date change entered in SNL
  entering change                               database:
  ----------------------------------------- --- --------------------------

UCI