JA Emilius Elections

Please enter your information to enroll/disenroll into the JA Emilius' 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.

Your Physician's name
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).
Please select if you like information about guaranteed issue accident and/or disability insurance otherwise select "Decline".
Clear Signature