Page 30 - Prestige Brochures & Enrollment Packet

Dependent Information Sheet

Please complete the following information for anyone to be covered

SPOUSE
Last Name First Name M.I. Jr. Sr. III?

Spouse Date of Birth Gender Spouse Smoker or Non-Smoker
M F

Spouse Address City State Zip Code

Spouse Phone # Spouse Occupation

Dependent Child #1
Last Name First Name M.I. Jr. Sr. III?

Child #1 Date of Birth Gender
M F

Dependent Child #2
Last Name First Name M.I. Jr. Sr. III?

Child #2 Date of Birth Gender
M F

Dependent Child #3
Last Name First Name M.I. Jr. Sr. III?

Child #3 Date of Birth Gender
M F

Dependent Child #4
Last Name First Name M.I. Jr. Sr. III?

Child #4 Date of Birth Gender
M F

Please let the Allstate Benefits Specialist know if you have more than 4 dependent children under the age of 26 and we
will give you an additional Depdendent Information sheet.