General Election Form | Quick Simple Onboarding

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

Company Name

Type of Change *

Health Insurance

Enter: "Waive" if you are NOT enrolling

Dental Insurance

Cigarette Smoker? *

Yes
No

Physician

Your Physician's name

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

Cigarette Smoker? *

Yes
No

Spouse's Health Insurance *

Enroll
Waive

Spouse's Dental Insurance *

Enroll
Waive

Spouse's Primary Physician

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

Cigarette Smoker? *

Yes
No

Child 1's Health Insurance *

Enroll
Waive

Child 1's Dental Insurance *

Enroll
Waive

Child 1's Primary Physician

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

Cigarette Smoker? *

Yes
No

Child 2's Health Insurance *

Enroll
Waive

Child 2's Dental Insurance *

Enroll
Waive

Child 2's Primary Physician

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

Cigarette Smoker? *

Yes
No

Child 3's Health Insurance *

Enroll
Waive

Child 3's Dental Insurance *

Enroll
Waive

Child 3's Primary Physician

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

Cigarette Smoker? *

Yes
No

Child 4's Health Insurance *

Enroll
Waive

Child 4's Dental Insurance *

Enroll
Waive

Child 4's Primary Physician

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

Cigarette Smoker? *

Yes
No

Child 5's Health Insurance *

Enroll
Waive

Child 5's Dental Insurance *

Enroll
Waive

Child 5's Primary Physician

Child 5's Insurance Effective Date *

Notes

Signature *