Date form submitted

Submitted by

E-Mail Address

Employer

Group Number

Location

Employee Name

Gender M F

Social Security Number

Date of Birth

Hire Date

Employee's Address

City

State

Zip Code

Employee's Telephone Numbers

Home

Work

Coverage applying for Please Select One Individual Family Other (please specify)

If Other, please explain

Type of Coverage
Please Select All Coverages Applicable Medical Dental Vision EAP - Employee Assistance Program FSA - Flexible Spending Account Other (please specify)

If Other, please explain

Effective Date of Coverage

Qualifying Event Date

Qualifying Event Code
Please Select One T - Termination R - Resignation RT - Retirement RH - Reduction of Hours D - Death DV - Divorce LS - Legal Separation DI - Dependent Ineligible ME - Medicare Entitlement EL - Eligible Leave DIS - Disability

Transaction Code
Please Select One E - New Enrollment TC - Terminated DC - Dropped Coverage AD - Add Dependent(s) DD - Drop Dependent(s) CS - Change Status (explain)

Change Status Explanation

Terminated Employee's Address (if COBRA eligible ONLY)

Flexible Spending Amount

DEPENDENT INFORMATION
Name
M F SSN DOB Relationship
Name
M F SSN DOB Relationship
Name
M F SSN DOB Relationship
Name
M F SSN DOB Relationship
Name
M F SSN DOB Relationship
Name
M F SSN DOB Relationship

Is Employee Covered by any other insurance plan? Yes No
If Yes, what company?

Additional Information