Employee Insurance Application
Employees, please answer all questions to avoid delay. A representative from Conway Financial Services will be in touch with any additional questions.
Employer: Company Name
*
Are you a full time, active employee?
Yes
If no, give reason below.
Select Your Salary Type
*
Hourly
Weekly
Monthly
Yearly
Salary Earnings
*
Average hours worked per week
*
Date of Hire
*
-
Month
-
Day
Year
Date
Employee Name (Last, First, Middle Initial)
*
Job Title
*
Employee Address
*
Physical Address (NO P.O. Boxes)
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Social Security Number
*
Home/Cell Phone
*
E-Mail Address
*
example@example.com
Date of Birth (MM/DD/YYYY)
*
/
Month
/
Day
Year
Date
Gender
*
Male
Female
Martial Status
*
Married
Single
Divorced
Widowed
Language Preference, if not English
Do you use tobacco?
*
Yes
No
Medical Coverage
Do you want to DECLINE Medical Coverage?
*
Yes
No
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Waiver of Medical Coverage
I understand that by waiving coverage at this time, I will not be allowed to participate unless I qualify at a special enrollment period or as a late enrollee, if applicable, or at the next open enrollment period. Dental and Vision coverage not included in this waiver.
Select all that apply. I decline medical coverage for:
Myself
Spouse
Dependents
Please select the reason for declining coverage:
Spouse's Employer's Plan
Covered by Medicare/CHIP or State-sponsored coverage
COBRA from Prior Employer
Tri-Care
Enrolled in other insurance plan
Other
Date
-
Month
-
Day
Year
Date
Signature
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Medical Coverage Enrollment Info
Rows
Last, First, Middle Name
Relationship
Date of Birth
Social Security #
Gender
Spouse
Spouse
Child
Stepchild
M
F
Dependent 1
Spouse
Child
Stepchild
M
F
Dependent 2
Spouse
Child
Stepchild
M
F
Dependent 3
Spouse
Child
Stepchild
M
F
Dependent 4
Spouse
Child
Stepchild
M
F
Dependent 5
Spouse
Child
Stepchild
M
F
Dependent 6
Spouse
Child
Stepchild
M
F
Who is applying? Coverage desired for:
Employee Only
Employee & Spouse
Employee & Child(ren)
Employee, Spouse, & Child(ren)
Other Medical Coverage: Within the last 12 months, have you, your spouse, or your dependents had any other medical coverage? If yes, please check all that apply.
Employee
Spouse
Dependents
No other medical coverage
Are any household members currently enrolled in Medicare?
Yes
No
Life Insurance Beneficiary Full Name and Address
Rows
First and Last Name
Date of Birth
Relationship
Social Security #
Primary Beneficiary 1:
Primary Beneficiary 2:
Secondary Beneficiary 1
Secondary Beneficiary 2
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Dental/Vision Coverage
Do you want to enroll in Dental and/or Vision coverage?
Yes
No
Who is applying for Dental and/or Vision? Coverage desired for:
Employee Only
Employee & Spouse
Employee & Child(ren)
Employee, Spouse, & Child(ren)
Dental / Vision Enrollment Info: List all enrolling members.
Rows
Last, First, Middle Name
Dental
Vision
Relationship
Date of Birth
Social Security #
Gender
Employee
Self
Spouse
Child
Stepchild
M
F
Spouse
Self
Spouse
Child
Stepchild
M
F
Dependent 1
Self
Spouse
Child
Stepchild
M
F
Dependent 2
Self
Spouse
Child
Stepchild
M
F
Dependent 3
Self
Spouse
Child
Stepchild
M
F
Dependent 4
Self
Spouse
Child
Stepchild
M
F
Dependent 5
Self
Spouse
Child
Stepchild
M
F
Are covered employee, spouse or dependents experiencing any of the following?
Rows
Pregnancy
Diabetes
Heart Disease
None of These
Employee
Spouse
Dependents
What is your reason for declining dental or vision coverage (please check all that apply)?
Already Covered
Already Covered on Spouse's Group Coverage
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Voluntary Life insurance, Disability, or Basic Life and AD&D coverage
If offered by your employer, are you interested in enrolling in Voluntary Life Insurance, Disability, or Basic Life and AD&D Coverage?
Yes
No
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Voluntary Life Coverage
If you (the employee) are age 70 or older: The guaranteed amount available to you and your spouse without answering health questions (Guarantee Issue Amount) and the life insurance benefit amount elected are subject to benefit reductions due to your age. At age 70, the guaranteed amount and the benefit elected decrease to 65% of the original amount. At age 75, amounts decrease to 45%. At age 80, amounts decrease to 30%. At age 85, amounts decrease to 20%. At age 90, amounts decrease to 15%. As your life insurance benefit amount decreases, your premium amount will also decrease. If applicable, reduced benefit amounts may be shown below. If you are enrolling for Voluntary Term Life coverage in excess of the Guarantee Issue Amount of 5 times your annual salary or $50,000 (whichever is less), or if your spouse is enrolling for coverage in excess of $25,000, you must complete and submit an Evidence of Insurability form. The form is available from your employer, or complete online. The following eligibility guidelines apply for dependent coverage: *You must be age 69 or less for your dependent spouse to be eligible for coverage. Spouse coverage terminates when you (the employee) attain the age of 70. If any premium is paid for spouse coverage after you attain age 70, the premium will be refunded in accordance with the terms of the policy. **Your dependent child(ren) must be under age 21 (under age 25 if a full-time student). If any premium is paid for child(ren) coverage after your child(ren) attain the limiting age, the premium will be refunded in accordance with the terms of the policy.
Rows
Benefit Amount
Other Amount ( if not listed)
Employee
$10,000
$10,000 (per child)
$20,000
$30,000
$40,000
$50,000
Other Amount
Decline
Spouse
$10,000
$10,000 (per child)
$20,000
$30,000
$40,000
$50,000
Other Amount
Decline
Children
$10,000
$10,000 (per child)
$20,000
$30,000
$40,000
$50,000
Other Amount
Decline
Employee Only: Are you interested in Voluntary Short-term Disability?
Yes
No
Employee Only: Voluntary Short-Term Disability Information
Rows
Annual Salary
(if applicable)
Hourly Rate
(if applicable)
Job Title
Employee:
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Have you, your spouse, or your children had Medicare coverage?
Yes
No
Census Information (optional)
Responding to this question is optional and is not required. Data collected in this section will be used only to help communicate with enrollees and inform them of specific programs to enhance their well-being. This information will not be used in the eligibility process.
RACE (CHECK ALL THAT APPLY)
White, European
Black, African-American
Asian
Native Hawaiian/Pacific Islander
Hispanic or Latino Origin
American Indian/Alaska Native
Other
Are you Hispanic or Latino in Origin?
yes
no
Signature
*
Initials
*
Signature Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: