Fellow Travelers Disability & Accident Insurance ENROLLMENT

Please enter your information to enroll/disenroll into the USFWC 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. The USFWC strives to be a trans-affirming organization, so if it is accurate to refer to you as a name or gender different from your legal name/gender, in that case that it is necessary to communicate with you or your co-op regarding your plan, please indicate that in the 'notes' field.

All voluntary elections require a $2 monthly ACH fee if you set up autopay via your checking account, or a $5 per month payment processing fee if not paying via autopay.

Name *

First

Middle

Last

Social Security Number / ITIN *

Address *

Address Line 1

City

State

Zip Code

Date of Birth *//

Email *

Personal Email preferred (not company work email)

Phone Number *

Legal Gender *

Female
Male

Associated Co-op/Business *

Date of Hire *//

Type of Change *

Accident Insurance Election *

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

Beneficiary for Accident Insurance

Accident Insurance contains a Life Insurance Benefit

Disability Insurance Election *

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

Monthly Disability Benefit (Enter as Dollar Amount) *

Enter the amount of money you want to receive each month from the insurance company. Must be in increments of $100 between $500 and $4000. NOTE: Disability Maximums for CT, MA, NJ, & WA

Do you have any medical conditions listed below? *

Yes
No

WITHIN PAST 12 MONTHS: HIV / AIDS or related complex (ARC), pregnancy, heart attack or surgery, stroke, leukemia, Hodgkins Disease, Hepatitis B or C, Diabetes diagnosed prior to age 40, Blood pressure of 140/100 or above, Ischemic Attack, Congestive Hear Failure, Cancer, Kidney or Renal Disease, Cirrhosis or other liver condition.

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).

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 Accident 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 Accident 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 Accident 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 Accident 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 Accident 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 Accident Insurance *

Enroll
Waive

Child 5's Insurance Effective Date *

Notes

Signature *