Employee Insurance Form

"*" indicates required fields

Marital Status:*

Health Insurance

Plan 1*
Plan 2*
Plan 3*

MEC Plans

PRO*
PRO+*
Advantage*

Dental

Basic*
Enhanced*
Freedom*

Vision

Vision*

Reliance

VOL Add*
Basic Add*
Basic Add*
Group Life*

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

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

554 W Main Street, Suite 400 | Buford, GA 30518 | (770) 932 1999
114 Curran Lane, #B2 | Lafayette, LA 70506 | (337) 534 0756
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EE Enrollment Form RV 01/13/2023