| Please fill out all of the areas below completely to be enrolled in Medical, Prescription, Dental, Vision and Group Life Insurance on your first day of employment. |
Date:
Date of Hire \ Effective Date
Employer Name:
Store Location Code
Store Email (Required):
Employee Last Name:
Employee First Name:
Employee Middle Initial:
Social Security Number (Required):
Home Street Address:
Street Address (cont):
City:
State:
Zip code:
County:
Phone (H):
Phone (W):
Phone (Mobile):
Home Email (optional):
Marital Status:
Employee Birth Date:
Gender:
Male
Female
Job Title (Required)
Average hours worked per week
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List all dependents to be covered: |
Spouse
Last Name
First Name
MI
Gender
M
F
Date of Birth
Social Security Number
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Dependent 1
Last Name
First Name
MI
Gender
M
F Date of Birth
Social Security Number
Relationship Code
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Dependent 2
Last Name
First Name
MI
Gender
M
F Date of Birth
Social Security Number
Relationship Code
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Dependent 3
Last Name
First Name
MI
Gender
M
F Date of Birth
Social Security Number
Relationship Code
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Dependent 4
Last Name
First Name
MI
Gender
M
F Date of Birth
Social Security Number
Relationship Code
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If the permanent address of the spouse or dependent is different than the address above, complete the following information: |
Full Name of Spouse or Dependent (1):
Street Address:
City:
State:
Zip:
Full Name of Spouse or Dependent (2):
Street Address:
City:
State:
Zip:
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Coordination of benefits information |
Do you, your spouse or dependent(s) maintain other health coverage?
Y
N
Check here if this applies to all members on the contract
If yes, complete below:
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Full Name of Person Covered (1):
Employer / Group name:
Policy Number:
Carrier:
Address:
Full Name of Person Covered (2):
Employer / Group name:
Policy Number:
Carrier:
Address:
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Are any members listed enrolled in Medicare?
Y
N
Medicare Claim #
If yes, check reason category
Working Aged
Retired
Disabled
ESRD |
Life Insurance Beneficiary Information |
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Primary 1
Full Name:
Address:
Social Security Number:
Relationship:
Date of Birth:
Percentage:
|
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Primary 2
Full Name:
Address:
Social Security Number:
Relationship:
Date of Birth:
Percentage:
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Primary 3
Full Name:
Address:
Social Security Number:
Relationship:
Date of Birth:
Percentage:
|
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Contingent 1
Full Name:
Address:
Social Security Number:
Relationship:
Date of Birth:
Percentage:
|
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Contingent 2
Full Name:
Address:
Social Security Number:
Relationship:
Date of Birth:
Percentage:
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Contingent 3
Full Name:
Address:
Social Security Number:
Relationship:
Date of Birth:
Percentage:
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If you elect not to enroll in medical prescription, dental, and vision coverage, please check here:
Note: You will still receive group life insurance. |
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