New Moon Election

Form Instructions
Please enter your information to enroll/disenroll into the New Moonbenefit 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.
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Field is required!
First Name
Your First Name
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Last Name
Your Last Name
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Field is required!
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
- select a state -
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Zipcode
Zipcode
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Date of Birth
Your 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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Field is required!
Type of Change
  • - select a option -
  • New Election
  • Change My Info
  • Terminate Coverage
- select a option -
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Field is required!
Insurance Effective Date
Select a date
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Field is required!
Health Insurance
  • - select a option -
  • Kaiser Core VisitsPlus Silver
  • Waive: I decline health insurance
- select a option -
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Field is required!
Your Physician:
Doctor/Practice Name:
Doctor/Practice Name
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Dental Insurance
  • - select a option -
  • USFWC PPO Dental
  • Waive: I decline dental insurance
- select a option -
Field is required!
Field is required!
Vision Insurance
  • - select a option -
  • USFWC Eyemed Vision
  • Waive: I decline vision insurance
- select a option -
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Field is required!
Would you like information about disability / accident insurance?
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Dependents to Enroll
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Field is required!
Dependents to Enroll
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Field is required!
Spouse First Name
Spouse's First Name
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Field is required!
Spouse Last Name
Spouse's Last Name
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Spouse Date of Birth
Spouses Date of Birth
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Spouse SSN
Spouse's Social Security Number
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Field is required!
Spouse's Gender
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Insurance Effective Date
Select a date
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Field is required!
Dental Insurance
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Field is required!
Vision Insurance
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Field is required!
Child 1 First Name
Child 1 First Name
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Field is required!
Child 1 Last Name
Child 1 Last Name
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Field is required!
Child 1 Date of Birth
Child 1 Date of Birth
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Field is required!
Child 1 SSN
Child 1 Social Security Number
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Field is required!
Child 1 Gender
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Field is required!
Insurance Effective Date
Select a date
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Field is required!
Child 1 Dental Insurance
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Field is required!
Child 1 Vision Insurance
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Field is required!
Child 2 First Name
Child 2 First Name
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Field is required!
Child 2 Last Name
Child 2 Last Name
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Field is required!
Child 2 Date of Birth
Child 2 Date of Birth
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Field is required!
Child 2 SSN
Child 2 Social Security Number
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Field is required!
Child 2 Gender
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Field is required!
Insurance Effective Date
Select a date
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Field is required!
Child 2 Dental Insurance
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Field is required!
Child 2 Vision Insurance
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Field is required!
Child 3 First Name
Child 3 First Name
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Field is required!
Child 3 Last Name
Child 3 Last Name
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Field is required!
Child 3 Date of Birth
Child 3 Date of Birth
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Field is required!
Child 3 SSN
Child 3 Social Security Number
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Field is required!
Child 3 Gender
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Field is required!
Insurance Effective Date
Select a date
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Field is required!
Child 3 Dental Insurance
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Field is required!
Child 3 Vision Insurance
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Field is required!
Child 4 First Name
Child 4 First Name
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Field is required!
Child 4 Last Name
Child 4 Last Name
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Field is required!
Child 4 Date of Birth
Child 4 Date of Birth
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Field is required!
Child 4 SSN
Child 4 Social Security Number
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Field is required!
Child 4 Gender
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Field is required!
Insurance Effective Date
Select a date
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Field is required!
Child 4 Dental Insurance
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Field is required!
Child 4 Vision Insurance
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Field is required!
Child 5 First Name
Child 5 First Name
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Field is required!
Child 5 Last Name
Child 5 Last Name
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Field is required!
Child 5 Date of Birth
Child 5 Date of Birth
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Field is required!
Child 5 SSN
Child 5 Social Security Number
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Field is required!
Child 5 Gender
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Field is required!
Insurance Effective Date
Select a date
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Field is required!
Child 5 Dental Insurance
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Field is required!
Child 5 Vision Insurance
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Field is required!
Signature
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