Enrollment
Please Populate Below And Click Enroll At Bottom When Finished
Name
First Name
Last Name
VA Medical Center
Home Address
Street Address
City
State
Zip Code
Date of Birth
/
Month
/
Day
Year
Date of Hire
/
Month
/
Day
Year
Social Security Number:
*
Male
Female
RN
ARNP
Annual Salary Guesstimate
*
Cell Number
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
E-Mail Personal
Selection of Benefits
The Standard Short Term Disability Payable Up To 6 Months Per Claim
$2000 Monthly Tax Free Benefit $41 Biweekly Premium
$2500 Monthly Tax Free Benefit $50 Biweekly Premium
$3000 Monthly Tax Free Benefit $60 Biweekly Premium
$3500 Monthly Tax Free Benefit $70 Biweekly Premium
$4000 Monthly Tax Free Benefit $79 Biweekly Premium
$4500 Monthly Tax Free Benefit $89 Biweekly Premium
$5000 Monthly Tax Free Benefit $98 Biweekly Premium
$5500 Monthly Tax Free Benefit $108 Biweekly Premium
$6000 Monthly Tax Free Benefit $117 Biweekly Premium
The Standard Short Term Disability Payable Up To 12 Months Per Claim
$2000 Monthly Tax Free Benefit $53 Biweekly Premium
$3000 Monthly Tax Free Benefit $79 Biweekly Premium
$3500 Monthly Tax Free Benefit $92 Biweekly Premium
$4000 Monthly Tax Free Benefit $105 Biweekly Premium
$4500 Monthly Tax Free Benefit $118 Biweekly Premium
$5000 Monthly Tax Free Benefit $131 Biweekly Premium
$5500 Monthly Tax Free Benefit $143 Biweekly Premium
$6000 Monthly Tax Free Benefit $156 Biweekly Premium
Aflac Accident
Employee $17 Biweekly Premium
Employee & Spouse $23 Biweekly Premium
Employee & Children Under Age 26 $27 Biweekly Premium
Employee, Spouse & Children Under Age 26 $33 Biweekly Premium
Aflac Cancer
Employee $30 Biweekly Premium
Employee & Spouse $50 Biweekly Premium
Employee & Children Under Age 26 $30 Biweekly Premium
Employee, Spouse & Children Under Age 26 $50 Biweekly Premium
MassMutual Whole Life Insurance
Please Select
$25,000
$50,000
$75,000
$100,000
$150,000
For Biweekly Cost Download PDF
Beneficiary
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Relasonship
MassMutual Whole Life Insurance Spouse
Please Select
$25,000
$50,000
The Policyholder will be the beneficiary unless otherwise noted.
Dependent Information
Only Populate If Adding Spouse & Dependent Children Age 26 And Younger
Spouse
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Relasonship
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Relasonship
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Relasonship
Mother Maiden Name For Signature
*
Enroll
Should be Empty: