FS1 / Mintt Elections | Quick Simple Onboarding

DO NOT COMPLETE IF: you have not been employed with FS1 or Mintt for at least one full year. You are eligible if you have been employed for ONE full year and worked at least 30 hours per week.

IF ELIGIBLE: This insurance REQUIRES you to pay for the cost of insurance above $100 per month.

Name *

First

Last

Social Security Number *

Address *

Address Line 1

City

State

Zip Code

Date of Birth *//

Email *

Phone Number *

Legal Gender *

Female
Male

Date of Hire *//

Type of Change

Health Insurance *

If you are currently enrolled and you select "Waive" you will be REMOVED from the insurance

Cigarette Smoker? *

Yes
No

Insurance Start / Effective Date *

Please choose the date the insurance "turn on" / go into effect. Effective dates can ONLY be on the first day of the month (i.e. No mid-month effective dates).

New York Health Insurance Marketplace

Terms of Agreement *

I understand that FS1/Mintt will pay $100 a month towards the cost of my health insurance obtained thru the state of New York's health insurance exchange. I also understand dependents / family members are not eligible to participate in the Flagship One ICHRA plan. I understand my portion of the premium payment will be collected via Payroll Deduction from my paycheck. I am responsible for paying for the insurance and submitting proof of payment to be reimbursed.

YOU ARE AGREEING TO PAY any costs / premiums over the first $100 per month for the health insurance! FS1 / Mintt will pay the first $100, you will pay the rest.

Notes

Signature *