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Employee Health Insurance Form
Employee Health Insurance Form
If you are human, leave this field blank.
Name of Employer
*
Number of employees on payroll
*
The average total number of employees (ATNE).
Medical coverage tier
*
EE
ES
EC
Fam
Waive
Tier of medical coverage interested in: EE-employee only, ES-employee and spouse, EC-employee and child, Fam-family coverage, Waive-not interested in benefits
Beneficiary Information
Name of benefit eligible employee first. Click below to add spouses or dependents.
First name
*
Last name
*
Date of birth
*
Gender
*
Male
Female
Other
Tobacco use?
*
No
Yes
Disabled?
*
Yes
No
If the employee/dependent is out on disability
Zip code
*
Zip code of home address
COBRA
*
Yes
No
Is employee/dependent on COBRA?
Employee/Dependent Indicator
*
EE
SP
CH
Indication of EE-employee, SP-spouse, CH-child
Add Spouse or Dependent
Remove Spouse or Dependent
Submit