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
2 digit month, 2 digit day, 4 digit year
Date of Hire
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Social Security Number:
*
Male
Female
RN
ARNP
Annual Salary Guesstimate
*
Mobile Number
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
E-Mail Personal
Selection of Benefits
Standard Short Term Disability
Please Select
$2000 Monthly Benefit Premium $53 Biweekly
$2500 Monthly Benefit Premium $67 Biweekly
$3000 Monthly Benefit Premium $79 Biweekly
$3500 Monthly Benefit Premium $92 Biweekly
$4000 Monthly Benefit Premium $105 Biweekly
$4500 Monthly Benefit Premium $118 Biweekly
$5000 Monthly Benefit Premium $131 Biweekly
$5500 Monthly Benefit Premium $143 Biweekly
$6000 Monthly Benefit Premium $156 Biweekly
Standard Hospital Indemnity
Employee $21 Biweekly Premium
Employee & Spouse $40 Biweekly Premium
Employee & Children Under Age 26 $29 Biweekly Premium
Employee, Spouse & Children Under Age 26 $45 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
Coverage cost and benefits may vary by state.
MassMutual Whole Life Insurance Employee
Please Select
$25,000
$50,000
$75,000
$100,000
$150,000
MassMutual Whole Life Insurance Spouse
Please Select
$25,000
$50,000
MassMutual Whole Life Insurance Children & Grandchildren Age 26 And Younger
Please Select
$25,000
$50,000
Dependent Information
Only Populate If Adding Spouse & Children Age 26 And Younger
Spouse
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Relasonship
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relasonship
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relasonship
Mother Maiden Name For Signature
*
Enroll
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