USFWC Disability & Accident Insurance ENROLLMENT

Form Instructions
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Field is required!
Form Instructions
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Field is required!
Legal First Name
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Legal Last Name
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Social Security Number or Taxpayer ID
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Address
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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
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Date of Birth
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Email Address
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Phone Number
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Legal Gender
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Date of Hire
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Type of Change
  • - select a option -
  • New Election
  • Change my Info / Coverages
  • Terminate ALL disability & accident coverage
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Field is required!
Accident Insurance Election
  • - select a option -
  • Named Insured
  • Employee + Partner
  • One Parent Family
  • Two Parent Family
  • Decline Coverage
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Field is required!
Disability Insurance Election
  • - select a option -
  • Disability Insurance (Standard)
  • Disability Insurance (ON JOB COVERAGE)
  • Decline Coverage
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Field is required!
Monthly Disability Benefit (Enter as Dollar Amount)
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Associated Co-op / Business
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Insurance Effective Date
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Notes:
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Dependents to Enroll
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Dependents to Enroll
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Fee Disclosure
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Spouse First Name
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Spouse Last Name
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Spouse Date of Birth
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Spouse SSN
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Spouse's Gender
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Child 1 First Name
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Child 1 Last Name
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Child 1 Date of Birth
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Child 1 SSN
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Child 1 Gender
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Child 2 First Name
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Child 2 Last Name
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Child 2 Date of Birth
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Child 2 SSN
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Child 2 Gender
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Child 3 First Name
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Child 3 Last Name
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Child 3 Date of Birth
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Child 3 SSN
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Child 3 Gender
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Child 4 First Name
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Child 4 Last Name
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Child 4 Date of Birth
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Child 4 SSN
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Child 4 Gender
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Child 5 First Name
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Child 5 Last Name
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Child 5 Date of Birth
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Child 5 SSN
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Child 5 Gender
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Signature
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