JQ Associates Elections - Quick Simple OnboardingQuick Simple Onboarding

You are eligible if you have been employed with JQ Staffing for at least one full year and worked a minimum of 30 hours per week. Do not complete if these conditions have not been met.

IF ENROLLING: This insurance REQUIRES you to pay 9.96% of your gross income / paycheck towards the cost of the insurance.

The insurance is prepaid so you MUST give notice if you intend on ending your employment with JQ Staffing. Any prepaid premiums will be withheld from your final paycheck, and any refunds will be issued directly to you from the insurance company.

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 *

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

2026 Bronze Summary

2026 Bronze Monthly Price

Terms of Agreement & YOUR PAYMENT *

IF I ENROLL: I understand that I will pay for my health insurance. I also understand dependents / family members are not eligible to participate in this ICHRA plan. I understand that if I am a "smoker", that I will be responsible for paying any additional premiums for being a smoker. I understand my portion of the premium payment will be collected via Payroll Deduction from my paycheck. I am responsible for paying for the insurance and submitting proof of payment to be reimbursed.

IF I ENROLL, I understand that I must give notice prior to ending my employment with JQ Staffing. Any prepaid premiums will be withheld from my final paycheck.
I am agreeing to pay 9.96% of my income towards the cost of the health insurance.

Notes

Signature *

Clear Signature