To add new employees, complete the form below:

Group/Unit/Cert Number: //    Social Security Number (no dashes):
Employee Name: First Last
Street Address:
City/State/Zip:   
Sex: Male Female Date of Birth (MM/DD/YYYY):   Marital Status: Married Single
Date of Hire (MM/DD/YYYY):
Medical Coverage: Select Employee Only Employee/Spouse Employee/Child(ren) Life: Select Yes No Dental: Select Yes No STD: Select Yes No LTD: Select Yes No
Effective Date: (MM/DD/YYYY) Plan: Plan 1 (90/60) Plan 2 (80/50) Deductible: $250 $500 $1,000 $2,000 $3,000
Status: Select Active Terminated COBRA Termination Date (MM/DD/YYYY): COBRA Effective Date:
Primary Care Physician (N/A if None)
Spouse Employer: Spouse Employer Phone:
Other Insurance Company Name: Policy Number:
Other Insurance Effective Date: