Employee Registration

EMPLOYER NAME

The Employer name field is required.

EMPLOYEE INFORMATION

Last Name field is required.

First Name field is required.

Suffix

Address field is required.

City field is required.

State field is required.

Zip field is required.

Email field is required.

Phone field is required.

Password (at least 8 characters including number and uppercase) field is required.
at least 8 characters including number and uppercase

Verify Password field is required. Does not match

Marital Status:

Single Married Divorced Widowed

Please Pick One.

Employment Status:

Full Time Part Time Independent Contractor Retired

Hire Date:

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Hire Date is required.

Annual Salary:
Annual Salary field is required.
Numbers only please.

Do you intend to Enroll or Waive:

Enroll Waive

Please Pick One.

If I have waived coverage for myself and/or my dependents (including my spouse) because of other health insurance coverage, I may in the future be able to enroll myself and/or my dependents in the coverage, provided that I request enrollment within 31 days after my other coverage ends because of involuntary loss of other coverage (divorce, death, legal separation, termination of employment, reduction in number of hours of employment). In addition, if I have a new dependent as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll my dependents, provided that I request enrollment within 31 days after the date of the event. I further understand that if I am considered a late enrollee, I may be declined from coverage or excluded from coverage for a period of time as defined in and where permitted by law, and I may be required to provide, where allowed by law, Medical History satisfactory to the Plan Sponsor or Administrator, for myself and/or my dependents.
Reason for Waiving Coverage? Please Pick One.

Other group/individual plan Medicare Medicaid No Coverage Other

	Last Name	First Name	DoB	Height	Weight	SSN
Employee	Required	Required	Required	ft. in.Required Required	lb. Required	Required
Spouse	Required	Required	Required	ft. in.Required Required	lb. Required	Required
Domestic Partner	Required	Required	Required	ft. in.Required Required	lb. Required	Required
Child	Required	Required	Required	ft. in.Required Required	lb. Required	Required

Authorization to Release Medical Information for Enrollment

I also hereby authorize any physician, medical practitioner, hospital, clinic, Veterans administrations facility, other medical or medically related facility, insurance or reinsurance company, pharmacy, pharmacy benefit manager, health plan, or Consumer Reporting Agency, having information available as to diagnosis, treatment and prognosis with respect to any physical or mental condition, including drug or alcohol abuse, and/or treatment of me or my minor children and other non-medical information of me and my minor children, to release to the third party administrator, any other excess loss insurance carrier designated by the Plan, or its legal representative, any and all such information as required for determination of eligibility for benefits. I also understand that my dependents of legal age, in order to be eligible for benefits, may be required to sign a similar release of medical records for the purpose of determining the accuracy of statements made by me on this application and for the ultimate determination of eligibility for benefits under the Plan. I understand that I may request a copy of this authorization at any time. I understand that any information that is disclosed pursuant to this authorization may be re-disclosed and no longer covered by federal rules governing privacy and confidentiality of health information. I agree that a photographic copy of this authorization shall be as valid as the original, and that this authorization shall be valid for 2 ½ years from the date shown below. I understand the information obtained by use of this authorization may be used by the Plan Sponsor, third party administrator, and any excess loss insurance carrier designated by the Plan to determine eligibility for health coverage, and eligibility for benefits under an existing plan, for myself and my dependents. Any information obtained will not be released to any person or organization, except to reinsuring companies or other persons or organizations performing business or legal services in connection with my enrollment for the coverage, for any claim, for medical management purposes, or as may be otherwise lawfully required or as I may further authorize. I also understand that I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization.

If signed by a representative of enrollee, please indicate the representative’s authority to act on behalf of employee:

Employee Agreement

I affirm that I have reviewed all responses provided within this form about me and my dependents. Furthermore, I attest that they are true and correct to the best of my knowledge and that no material information has been withheld or omitted.

I understand that the previous answers will be relied upon by the Plan Sponsor in the issuance of a Summary Plan Description. I declare all statements contained in this entire form about me and my dependents are true and correct to the best of my knowledge and that no material information has been withheld or omitted. I understand that my intentional misrepresentation of a material fact or my failure to report information about me or my dependents may be used as the basis to rescind, terminate or modify coverage for me or my dependents. Rescind means that the coverage was never in effect. I understand and agree that the Plan Sponsor is not bound by any statement made by or to any agent unless written herein. I agree that no coverage will be effective until the date specified by the Plan Sponsor in the Summary Plan Description. The actual effective date may not be the requested effective date. If I am now waiving medical benefits for myself and/or my dependents, I have read the entire Waiver provision, and understand the enrollment requirements if I make request for such benefits at a later date. I authorize my employer to deduct the necessary contribution toward the benefits. I reserve the right to revoke this deduction authorization at any time upon my written notice. Benefits are effective only after approval by the Plan Sponsor or Administrator and satisfaction of any probationary period. Any person who knowingly and with intent to defraud, submits an application or files a claim containing any materially false information may be found guilty of fraud, which is a crime, in a court of law and may be subject to fines and confinement in prison. This will not be considered as a complete application unless all pages are attached and completed.

Please Check
I understand that information on this application is valid for a maximum of 90 days from the date of signature.
To be a valid enrollment, your signature and date are required. Please Check

Date:

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Employee Signature:

EMPLOYEE INFORMATION

COBRA INFORMATION

APPLICANT ENROLLMENT INFORMATION

Authorization to Release Medical Information for Enrollment

Employee Agreement

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