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Personal Data Change Form The Local Choice Program Instructions: Please print or type legibly - illegible forms will delay processing. Complete Participant (Subscriber) Information and then only those items to be changed. Your Benefits Administrator may require documentation before approving changes. Documentation is always required for Social Security Number changes. Participant (Subscriber) Information: Subscriber ID (or Social Security Number): Name shown on your identification card: First Name MI Last Name Date these changes are effective: Month: Day: Year: □Change my Name: First Name MI Last Name Suffix: (Jr, Sr, III) □Change my Address: Street or PO Box: City: - □Change my Phone Number(s): Work Phone: ( ) - Personal Phone: ( ) - □Change my Email(s): Email: □Change my Date of Birth / Gender: Month: Day: Year: □Female □Male □Change my covered Dependent’s Personal Data: (Codes: H=Husband, W=Wife, D=Daughter, S=Son, SD=Step-Daughter, SS=Stepson) Middle Date of Birth Social Security Number Code: First Name Initial Last Name, Suffix (Jr, Sr, II, III) (MM/DD/YYYY) (NNN-NN-NNNN) / / / / Your Return this completed from to your employer’s benefits administrator. Authorization of Employer’s Benefits Administrator: Please make sure this form is legible - illegible forms will delay processing. □I certify that the information on this form and in the required supporting documentation is complete and accurate to the best of my knowledge. Date Sent to DHRM: DHRM Group Authorized by: ( Send authorized form by: Email: [EMAIL REDACTED], Fax: (804) 786-1708, or Mail: DHRM – TLC, 101 N 14th St Fl 13, Richmond, VA 23219 TLC Personal Data Change Form.docx ! of 1 1 SIGN