Industrial Commons Election | Quick Simple Onboarding

Please enter your information to enroll/dis-enroll into the company benefit plans. If you want the benefit, make sure you 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. You are eligible to enroll 30 days after your date of hire and must work at least 30 hours per week

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 *

Dental Insurance *

Vision Insurance *

Primary Physician

Your Physician's name

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).

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 Health Insurance *

Enroll
Waive

Spouse's Dental Insurance *

Enroll
Waive

Spouse's Vision Insurance *

Enroll
Waive

Cigarette Smoker? *

Yes
No

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

Child 1's Health Insurance *

Enroll
Waive

Child 1's Dental Insurance *

Enroll
Waive

Child 1's Vision Insurance *

Enroll
Waive

Cigarette Smoker? *

Yes
No

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

Child 2's Health Insurance *

Enroll
Waive

Child 2's Dental Insurance *

Enroll
Waive

Child 2's Vision Insurance *

Enroll
Waive

Cigarette Smoker? *

Yes
No

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

Child 3's Health Insurance *

Enroll
Waive

Child 3's Dental Insurance *

Enroll
Waive

Child 3's Vision Insurance *

Enroll
Waive

Cigarette Smoker? *

Yes
No

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

Child 4's Health Insurance *

Enroll
Waive

Child 4's Dental Insurance *

Enroll
Waive

Child 4's Vision Insurance *

Enroll
Waive

Cigarette Smoker? *

Yes
No

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

Child 5's Health Insurance *

Enroll
Waive

Child 5's Dental Insurance *

Enroll
Waive

Child 5's Vision Insurance *

Enroll
Waive

Cigarette Smoker? *

Yes
No

Child 5's Primary Physician

Child 5's Insurance Effective Date *

Notes

Signature *