Spokane Workers Cooperative Election | Quick Simple Onboarding

Please enter your information to enroll/disenroll into the Spokane Workers Cooperative benefit plans. If you want the benefit, make sure to 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.

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

Dental Insurance *

If you are currently enrolled and you select "Waive" you will be REMOVED from the insurance. YOU MUST enroll into dental if you are enrolled in health insurance.

Primary Physician

Your Physician's name

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).

Dependents to Enroll

Spouse
Child 1
Child 2

Dependents to Enroll

Child 3
Child 4
Child 5

Spouse's Name *

First

Last

Spouse's Date of Birth *//

Spouse's SSN *

Spouse's Gender *

Female
Male

Spouse's Health Insurance *

Enroll
Waive

Spouse's Dental Insurance *

Enroll
Waive

Spouse's Vision Insurance *

Enroll
Waive

Cigarette Smoker? *

Yes
No

Spouse's Primary Physician

Spouse's Insurance Effective Date *

Child 1's Name *

First

Last

Child 1's Date of Birth *//

Child 1's SSN *

Child 1's Gender *

Female
Male

Child 1's Health Insurance *

Enroll
Waive

Child 1's Dental Insurance *

Enroll
Waive

Child 1's Vision Insurance *

Enroll
Waive

Cigarette Smoker? *

Yes
No

Child 1's Primary Physician

Child 1's Insurance Effective Date *

Child 2's Name *

First

Last

Child 2's Date of Birth *//

Child 2's SSN *

Child 2's Gender *

Female
Male

Child 2's Health Insurance *

Enroll
Waive

Child 2's Dental Insurance *

Enroll
Waive

Child 2's Vision Insurance *

Enroll
Waive

Cigarette Smoker? *

Yes
No

Child 2's Primary Physician

Child 2's Insurance Effective Date *

Child 3's Name *

First

Last

Child 3's Date of Birth *//

Child 3's SSN *

Child 3's Gender *

Female
Male

Child 3's Health Insurance *

Enroll
Waive

Child 3's Dental Insurance *

Enroll
Waive

Child 3's Vision Insurance *

Enroll
Waive

Cigarette Smoker? *

Yes
No

Child 3's Primary Physician

Child 3's Insurance Effective Date *

Child 4's Name *

First

Last

Child 4's Date of Birth *//

Child 4's SSN *

Child 4's Gender *

Female
Male

Child 4's Health Insurance *

Enroll
Waive

Child 4's Dental Insurance *

Enroll
Waive

Child 4's Vision Insurance *

Enroll
Waive

Cigarette Smoker? *

Yes
No

Child 4's Primary Physician

Child 4's Insurance Effective Date *

Child 5's Name *

First

Last

Child 5's Date of Birth *//

Child 5's SSN *

Child 5's Gender *

Female
Male

Child 5's Health Insurance *

Enroll
Waive

Child 5's Dental Insurance *

Enroll
Waive

Child 5's Vision Insurance *

Enroll
Waive

Cigarette Smoker? *

Yes
No

Child 5's Primary Physician

Child 5's Insurance Effective Date *

Notes

Signature *