JQ Associates Elections

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First Name
Your First Name
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Last Name
Your Last Name
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Social Security Number
Your Social Security Number
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Address
Your Address
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City
City
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State
  • - select a state -
  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming
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Zipcode
Zipcode
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Date of Birth
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Email Address
Your Email Address
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Phone Number
Your Phone Number
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Legal Gender
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Date of Hire
Date of Hire
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Type of Change
  • - select a option -
  • New Election
  • Open Enrollment Election
  • Change My Info
  • Terminate Coverage
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Health Insurance
  • - select a option -
  • HMO Bronze - I WILL PAY FOR IT
  • Waive: I decline health insurance
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Cigarette Smoker?
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Your Physician
Your Physician's Name
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Insurance Effective Date
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Dependents to Enroll
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Dependents to Enroll
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Spouse First Name
Spouse's First Name
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Spouse Last Name
Spouse's Last Name
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Spouse Date of Birth
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Spouse SSN
Spouse's Social Security Number
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Spouse's Gender
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Cigarette Smoker?
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Health Insurance
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Spouse's Primary Physician
Spouse's Primary Care Doctor
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Insurance Effective Date
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Child 1 First Name
Child 1 First Name
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Child 1 Last Name
Child 1 Last Name
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Child 1 Date of Birth
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Child 1 SSN
Child 1 Social Security Number
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Child 1 Gender
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Cigarette Smoker?
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Child 1 Health Insurance
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Child 1 Physician
Child 1 Primary Care Doctor
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Insurance Effective Date
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Child 2 First Name
Child 2 First Name
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Child 2 Last Name
Child 2 Last Name
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Child 2 Date of Birth
Child 2 Date of Birth
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Child 2 SSN
Child 2 Social Security Number
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Child 2 Gender
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Child 2 Cigarette Smoker?
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Child 2 Health Insurance
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Child 2 Physician
Child 2 Primary Care Doctor
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Insurance Effective Date
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Child 3 First Name
Child 3 First Name
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Child 3 Last Name
Child 3 Last Name
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Child 3 Date of Birth
Child 3 Date of Birth
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Child 3 SSN
Child 3 Social Security Number
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Child 3 Gender
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Child 3 Cigarette Smoker?
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Child 3 Health Insurance
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Child 3 Physician
Child 3 Primary Care Doctor
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Insurance Effective Date
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Child 4 First Name
Child 4 First Name
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Child 4 Last Name
Child 4 Last Name
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Child 4 Date of Birth
Child 4 Date of Birth
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Child 4 SSN
Child 4 Social Security Number
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Child 4 Gender
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Child 4 Cigarette Smoker?
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Child 4 Health Insurance
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Child 4 Physician
Child 4 Primary Care Doctor
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Insurance Effective Date
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Child 5 First Name
Child 5 First Name
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Child 5 Last Name
Child 5 Last Name
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Child 5 Date of Birth
Child 5 Date of Birth
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Child 5 SSN
Child 5 Social Security Number
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Child 5 Gender
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Child 5 Cigarette Smoker?
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Child 5 Health Insurance
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Child 5 Physician
Child 5 Primary Care Doctor
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Insurance Effective Date
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Payment Method
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Account Type
  • - select a option -
  • Checking
  • Savings
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Routing Number:
Routing Number:
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Account Number:
Account Number
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Card Type
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  • Visa
  • Mastercard
  • American Express
  • Discover
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Card Number:
Card Number
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Expiration Date:
Expiration Date:
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Signature
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