Page 22 - 2022 DPR Construction Benefit Guide_Craft Employees

Enrollment Form

You must complete this form (including date and signature) and return this form to your local Craft Contact Tear out at perforation.
within 30 days of your effective date listed below.

EMPLOYEE INFORMATION
Name Social Security #
Employee # Effective Date
Email Phone #
REASON FOR COMPLETING FORM
*If you are adding or deleting a dependent or changing your
New Employee
Open Enrollment election due to a qualifying event, please select your reason below:
Qualifying Event*
Qualifying Event Date:
Effective Date: Marriage* Formation of Domestic
Birth* Partnership*
Adoption* Divorce/Dissolution of
Gain/Loss of Coverage Domestic Partnership*
by Spouse*
Other ____________________________________________
* Requires documentation, please contact your local Craft Contact or
craftbenefits@dpr.com

DPR CONSTRUCTION REQUIRES ENROLLMENT INFORMATION FOR YOU AND YOUR DEPENDENTS
FIRST NAME, RELATIONSHIP CHANGE SEX DATE OF SOCIAL DISABLED? COVERAGE OPTIONS
LAST NAME BIRTH SECURITY NO.
Enroll M Yes Medical – OAP 90/70
Add F No Medical – OAP 80/60
Employee
Delete Dental PPO
Vision
Spouse Enroll M Yes Medical– OAP 90/70
Partner Add F No Medical – OAP 80/60
Delete Dental PPO
Vision
Enroll M Yes Medical – OAP 90/70
Add F No Medical – OAP 80/60
Child
Delete Dental PPO
Vision
Enroll M Yes Medical – OAP 90/70
Add F No Medical – OAP 80/60
Child
Delete Dental PPO
Vision
Enroll M Yes Medical – OAP 90/70
Add F No Medical – OAP 80/60
Child
Delete Dental PPO
Vision

Do you currently use tobacco? Yes No
If you wish to participate in a Tobacco Cessation Program to eliminate the weekly tobacco surcharge, DPR offers a reasonable alternative
standard if you are unable to quit tobacco use. The reasonable alternative standard is satisfied by cessation from tobacco use or participation
and completion of a tobacco use cessation course (as provided by your medical plan). Please contact craftbenefits@dpr.com for more
information about the reasonable alternative standard.

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