Mintt Management Election - Quick Simple OnboardingQuick Simple Onboarding

You are eligible if you have been employed with Mintt Management 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 ELIGIBLE: This insurance REQUIRES you to pay up to 9.96% of your annual salary towards health insurance.

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

Insurance Start / Effective Date *

Please choose the date the insurance "turn on or off" / go into effect. Effective dates can ONLY be on the first day of the month (i.e. No mid-month effective dates).

New York Health Insurance Marketplace

Terms of Agreement *

I understand my wages will be deducted to pay for my health insurance. I also understand dependents / family members are not eligible. I am responsible for paying for the insurance and submitting proof of payment to be reimbursed.

YOU ARE AGREEING TO PAY up to 9.96% of your annual salary for health insurance

Notes

Signature *

Clear Signature