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Brown Brown of New York Inc. dba Fitzharris Company 333 Earle Ovington Blvd. Suite 215 Uniondale NY 11553-3624 FAX 516 944-2953 U. T. I. T. WELFARE TRUST Person Completing Form Date Completed DENTAL 702 Effective // VISION 702 SINGLE FAMILY EMPL/SPOUSE EMPL/DEPENDENT Hire Date Occupation E-mail Phone // SECTION 1 Employee Information LAST NAME FIRST NAME MI SEX SOCIAL SECURITY NUMBER M F STREET ADDRESS / EMPLOYEE DATE OF BIRTH MONTH DAY YEAR MARITAL STATUS MARRIED WIDOWED OTHER CITY...

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