Alpha Data Systems, Inc.

WEB System

Employee Enrollment

Eligibility and Benefit Information        Claims Status & History

To add new employees, complete the form below:

Group/Unit/Cert Number: //    Social Security Number (no dashes):
Employee Name: First Last
Street Address:
Sex: Date of Birth (MM/DD/YYYY):   Marital Status:
Date of Hire (MM/DD/YYYY):
Medical Coverage: Life: Dental: STD: LTD:
Effective Date: (MM/DD/YYYY) Plan: Deductible:
Status: 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:


Dependent Entry

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