Employee Insurance Form

"*" indicates required fields

Client Name:*

Client Address:*

Employee Name:*

Hire Date:*

Employee Address:*

City:*

State:*

Zip:*

Employee DOB:*

SSN#:*

Email Address:*

Home Phone#

Marital Status:*

Married

Single

Divorced

Spouse:

SS#:

Dob:

Dep #1:

SS#:

Dob:

Dep #2:

SS#:

Dob:

Dep #3:

SS#:

Dob:

Insurance Effective Date:

Health Insurance

Plan 1*

Employee

Emp / Spouse

Emp / Children

Family

Health Insurance - Plan 1 - Per Pay Check*

Plan 2*

Employee

Emp / Spouse

Emp / Children

Family

Health Insurance - Plan 2 - Per Pay Check*

Plan 3*

Employee

Emp / Spouse

Emp / Children

Family

Health Insurance - Plan 3 - Per Pay Check*

MEC Plans

PRO*

Employee

Emp / Spouse

Emp / Children

Family

MEC Plans - PRO - Per Pay Check*

PRO+*

Employee

Emp / Spouse

Emp / Children

Family

MEC Plans - PRO+ - Per Pay Check*

Advantage*

Employee

Emp / Spouse

Emp / Children

Family

MEC Plans - Advantage - Per Pay Check*

Dental

Basic*

Employee

Emp / Spouse

Emp / Children

Family

Dental - Basic - Per Pay Check*

Enhanced*

Employee

Emp / Spouse

Emp / Children

Family

Dental - Enhanced - Per Pay Check*

Freedom*

Employee

Emp / Spouse

Emp / Children

Family

Dental - Freedom - Per Pay Check*

Vision

Vision*

Employee

Emp / Spouse

Emp / Children

Family

Vision - Per Pay Check*

Reliance

VOL Add*

Employee

Emp / Spouse

Emp / Children

Family

Reliance - VOL Add - Per Pay Check*

Vol Life*

Employee

Emp / Spouse

Emp / Children

Family

Reliance - Vol Life - Per Pay Check*

Consent*

I am declining coverage at this time. I understand that I will not be eligible for coverage again until group open enrollment (listed below), unless there is a life changing event that occurs, at which time I would have 30 days from loss of previous coverage to enroll.*

Health Insurance: Nov 1st – Nov 30th Coverage begins December 1st

Vision / Dental Insurance: April 1st – April 30th. Coverage would begin May 1st.

Supplemental Insurance (ie. Life, disability, etc): April 1st – April 30th. Coverage would begin May 1st.

MEC: Jan 1st – Jan 31st Coverage will begin February 1st

Signature*

Name

This field is for validation purposes and should be left unchanged.

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EE Enrollment Form RV 01/13/2023

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Phone

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