USFWC Election | Quick Simple Onboarding

Please enter your information to enroll/disenroll into the USFWC 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.

Due to the requirements of the companies that run these insurance plans, we must collect legal names and legal genders. The USFWC strives to be a trans-affirming organization, so if it is accurate to refer to you as a name or gender different from your legal name/gender, in that case that it is necessary to communicate with you or your co-op regarding your plan, please indicate that in the 'notes' field.

Legal First Name *

Legal Last Name *

Legal Middle Name (optional)

Social Security Number / ITIN *

Address *

Address Line 1

City

State

Zip Code

Date of Birth *

Email *

Phone Number *

Legal Gender *

Female
Male

Workplace Name *

Date of Hire *

Type of Change *

Dental Insurance *

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

Vision 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" / go into effect. Effective dates can ONLY be on the first day of the month (i.e. No mid-month effective dates). MUST BE WITHIN 2 MONTHS OF TODAY.

Dependents to Enroll

Partner
Child 1
Child 2

Dependents to Enroll

Child 3
Child 4
Child 5

Partner's First Name *

Partner's Last Name *

Partner's Date of Birth *

Partner's SSN *

Partner's Gender *

Female
Male

Partners's Dental Insurance *

Enroll
Waive

Partners's Vision Insurance *

Enroll
Waive

Partners's Insurance Effective Date *

Child 1's First Name *

Child 1's Last Name *

Child 1's Date of Birth *

Child 1's SSN *

Child 1's Gender *

Female
Male

Child 1's Dental Insurance *

Enroll
Waive

Child 1's Vision Insurance *

Enroll
Waive

Child 1's Insurance Effective Date *

Child 2's First Name *

Child 2's Last Name *

Child 2's Date of Birth *

Child 2's SSN *

Child 2's Gender *

Female
Male

Child 2's Dental Insurance *

Enroll
Waive

Child 2's Vision Insurance *

Enroll
Waive

Child 2's Insurance Effective Date *

Child 3's First Name *

Child 3's Last Name *

Child 3's Date of Birth *

Child 3's SSN *

Child 3's Gender *

Female
Male

Child 3's Dental Insurance *

Enroll
Waive

Child 3's Vision Insurance *

Enroll
Waive

Child 3's Insurance Effective Date *

Child 4's First Name *

Child 4's Last Name *

Child 4's Date of Birth *

Child 4's SSN *

Child 4's Gender *

Female
Male

Child 4's Dental Insurance *

Enroll
Waive

Child 4's Vision Insurance *

Enroll
Waive

Child 4's Insurance Effective Date *

Child 5's First Name *

Child 5's Last Name *

Child 5's Date of Birth *

Child 5's SSN *

Child 5's Gender *

Female
Male

Child 5's Dental Insurance *

Enroll
Waive

Child 5's Vision Insurance *

Enroll
Waive

Child 5's Insurance Effective Date *

Notes

Signature *