Fellow Travelers Association Election - Quick Simple OnboardingQuick Simple Onboarding

Please enter your information to enroll/disenroll into the Fellow Travelers benefit plans. If you want the benefit, make sure to select the plan you want. If you do not want the benefit, select "Waive". IF you are CURRENTLY enrolled and "Waive" is showing, you will be REMOVED from the insurance.

Due to the requirements of the companies that run these insurance plans, we must collect legal names and legal genders. If it is accurate to refer to you as a name or gender different from your legal name/gender, please indicate that in the 'notes' field.

Name *

First

Last

Social Security Number *

Address *

Address Line 1

City

State

Zip Code

Date of Birth *

Email *

Phone Number *

Legal Gender *

Female
Male

Associated Business

Name of company you are employed

Date of Hire *

Type of Change *

Dental Insurance *

Vision Insurance *

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).

Enroll Dependents

Dependents to Enroll

Spouse
Child 1
Child 2

Dependents to Enroll

Child 3
Child 4
Child 5

Spouse's Name *

First

Last

Spouse's Date of Birth *

Spouse's SSN *

Spouse's Gender *

Female
Male

Spouse's Dental Insurance *

Enroll
Waive

Spouse's Vision Insurance *

Enroll
Waive

Spouse's Insurance Effective Date *

Child 1's Name *

First

Last

Child 1's Date of Birth *

Child 1's SSN *

Child 1's Gender *

Female
Male

Child 1's Dental Insurance *

Enroll
Waive

Child 1's Vision Insurance *

Enroll
Waive

Child 1's Insurance Effective Date *

Child 2's Name *

First

Last

Child 2's Date of Birth *

Child 2's SSN *

Child 2's Gender *

Female
Male

Child 2's Dental Insurance *

Enroll
Waive

Child 2's Vision Insurance *

Enroll
Waive

Child 2's Insurance Effective Date *

Child 3's Name *

First

Last

Child 3's Date of Birth *

Child 3's SSN *

Child 3's Gender *

Female
Male

Child 3's Dental Insurance *

Enroll
Waive

Child 3's Vision Insurance *

Enroll
Waive

Child 3's Insurance Effective Date *

Child 4's Name *

First

Last

Child 4's Date of Birth *

Child 4's SSN *

Child 4's Gender *

Female
Male

Child 4's Dental Insurance *

Enroll
Waive

Child 4's Vision Insurance *

Enroll
Waive

Child 4's Insurance Effective Date *

Child 5's Name *

First

Last

Child 5's Date of Birth *

Child 5's SSN *

Child 5's Gender *

Female
Male

Child 5's Dental Insurance *

Enroll
Waive

Child 5's Vision Insurance *

Enroll
Waive

Child 5's Primary Physician

Child 5's Insurance Effective Date *

Notes

Terms of Agreement & Your Payroll Deductions *

I understand this is an IRS Section 125 Election and cannot be changed outside of open enrollment or a qualifying life event.

YOU ARE AGREEING that you understand this is a IRREVOCABLE IRS Section 125 election and cannot be changed until next open enrollment or a qualifying life event.

Signature *

Clear Signature