Employee Enrollment Application

Full Name *

Hire Date *

Date of birth *

Phone *

Email *

Address *

City *

State *

Zip code *

Spouse Name

spouse soc sec

spouse_dob

Spouse's Phone

Children's names, Soc Sec, DOB, Gender

If enrolling in the company ICHRA plan, you attest that you and all family members listed above are covered (or will be covered) by ACA qualified individual health coverage (or Medicare). This coverage is (or will be) effective on or before your company ICHRA plan effective date.

Opt-In or Opt-Out

Yes, Enroll Me in the ICHRA Plan

No, I Opt-Out of the ICHRA Plan

Signature

Clear

Captcha

_______________

Insurance Plans

Options Purchased

Company Area

PAL - New Era
ACA - HealthSherpa
Dental & Vision
MediShare
STM - IHC or UHC
MEC- Safeguard
Medicare Supp
Medicare Advantage
No elements found. Consider changing the search query.
List is empty.