Benefits

Select One *

Select Plan

Please select one

Please select one

Please select one

Please select one

Enrollment Data

Enroll spouse

Spouse's Legal name

Spouse's Social Security number

Spouse's Birth date

Spouse's Sex

Enroll child

Child's Legal name

Child's Social Security number

Child's Birth date

Child's Sex

Enroll a second child

Child's Legal name

Child's Social Security number

Child's Birth date

Child's Sex

Enroll a third child

Child's Legal name

Child's Social Security number

Child's Birth date

Child's Sex

Enroll a fourth child

Child's Legal name

Child's Social Security number

Child's Birth date

Child's Sex

Bi-weekly paycheck deduction $______ + 1.5% of wages (look up table—cost of plan based on number enrolled)

I have been informed about the benefit plans I have selected and understand the coverage period. Employee will be defaulted to the company base plan, single coverage, if application form is not submitted on time *