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50 Retiree Spouse/DP - 32. 00 Retiree Child ren - 32. 00 Retiree Family - 53. 00 Dental HMO - Select Facility on Reverse of this form Step 4 HYATT LEGAL PLAN Dental PPO Please note If you are currently on the Hyatt Legal Plan select No your plan will terminate July 31 2017 NO Hyatt Legal Plan YES Enroll Me - 21. Sdpeba.org 2a. DENTAL HMO FACILITY SELECTION DENTAL HMO FACILITY SELECTION To begin using services you MUST complete this section. You will NOT be auto assigned to a dental provider....
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