JQ Associates Elections

DO NOT COMPLETE IF: you have not been employed with JQ Staffing for at least one full year. You are eligible if you have been employed for ONE full year and worked at least 30 hours per week.

IF ELIGIBLE: This insurance REQUIRES you to pay 9.8% of your gross income towards the cost of the insurance.

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If you are currently enrolled and you select "Waive" 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).