Employee Health Insurance Form
The average total number of employees (ATNE).
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.
If the employee/dependent is out on disability
Zip code of home address
Is employee/dependent on COBRA?
Indication of EE-employee, SP-spouse, CH-child