You are not able to complete this form because you have signed the Waiver form. Please return to the Waiver form to submit or to clear your signature.
REQUIRED EMPLOYEE INFORMATION
Complete the Enrollment Form and return to your Human Resources Department.
BENEFIT PLAN SELECTION
Payroll Deducted Rates - Please select the tier for each product in which you wish to enroll.
You are not able to complete this form because you have declined both Medical and Dental Insurance. Please return to the first screen and change your selection to "Decline Insurance Benefits".
Please call 1.844.300.6497 to enroll.
REQUIRED DEPENDENT INFORMATION
You MUST sign and date to be enrolled in coverage
Any changes made to the Enrollment Form will require the changes to be dated and initialed by employee.
You MUST sign and date if you wish to decline coverage.
Waiver of Coverage: I, the undersigned employee, understand and acknowledge that: I have been offered an opportunity by my Employer to enroll in affordable employer-sponsored health coverage that meets the minimum value standard set forth in the Patient Protection and Affordable Care Act (ACA) for the applicable period:
You are not able to complete this form because you have signed the Enrollment form. Please return to the Enrollment form to submit or to clear your signature.