Medical Enrollment - Esparza Enterprises

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Today's Date

MM slash DD slash YYYY

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Initial Checkbox 1

Yes

Medical Enrollment Form

Date(Required)

MM slash DD slash YYYY

Employee Start Date:(Required)

EE#:(Required)

Social Security #:(Required)

Date of Birth:(Required)

Format MUST be MM/DD/YYYY

Name:(Required)

First Name Middle Iniitial Last Name

Email Address:

Address:(Required)

Street Address Apt/Unit# City State ZIP Code

Telephone:(Required)

SECTION 1. EMPLOYEE INFORMATION

Gender:(Required)

Male

Female

Marital Status:(Required)

Single

Separated

Divorced

Married

Domestic Partner

SECTION 2. QUALIFYING EVENT

This Election is For:

New Enrollment

SECTION 3. COVERAGE ELECTION: Medical

Accept or Decline(Required)

I WANT medical coverage

I DO NOT want medical coverage

Plan Choice (check one of the following boxes):(Required)

Plan 1 - Plus Plan

Plan 2 – Buy Up MV Plan

Plan 1 Options (check one of the following boxes):(Required)

Employee Only

EE + Child(ren)

Plan 2 Options (check one of the following boxes):(Required)

Employee Only (9.12% of income)

EE + Child(ren) (9.12% + 100% cost of dependent)

Relationship: Self

Status

Name

SSN

DOB

Gender

Relationship: Child(ren)

Child 1 Status

Child 1 Name (Last, First, MI)

Child 1 SSN

Child 1 DOB

Child 1 Gender

Child 2 Status

Child 2 Name (Last, First, MI)

Child 2 SSN

Child 2 DOB

Child 2 Gender

Child 3 Status

Child 3 Name (Last, First, MI)

Child 3 SSN

Child 3 DOB

Child 3 Gender

Child 4 Status

Child 4 Name (Last, First, MI)

Child 4 SSN

Child 4 DOB

Child 4 Gender

SECTION 4. DECLINATION OF COVERAGE

(Complete this section ONLY if declining coverage for yourself OR eligible dependents)

Decline:

(Check all that apply and give reason)

Self

Spouse / Domestic Partner

Child(ren)

Reason:

(Check all that apply and give reason)

Have Other Group Coverage

Have Other Individual Coverage

Other

Children:

Other Reason:

Signature of Employee:(Required)

I understand that if I refuse coverage now or if I later wish to enroll myself or my dependents, I will only be able to add coverage if I enroll coverage within 30 days of a Qualifying Event (see summary of plan for details).

SECTION 5. SIGNATURE OF EMPLOYEE

PLEASE READ PRIOR TO SIGNING – I accept the insurance provided by the Plan Sponsor and authorize the deductions in my earnings of the contribution required, if any, toward the cost of the premiums. I understand that if the prior information is not complete or is incorrect, this coverage may be terminated retroactively. I elect to participate in the section 125 Premium Only Plan established, maintained and administered by my employer. I authorize each salary payroll to be reduced on a pre-tax basis in accordance with the indicated elected benefits.

Signature of Employee:

Click Here to Download Policy Documents

Name

This field is for validation purposes and should be left unchanged.