New Enrollment Form

Enrollment

Please Populate Below And Click Enroll At Bottom When Finished
Name

First NameLast Name
VA Medical Center
Home Address

Street Address

CityState

Zip Code
Date of Birth

MonthDayYear
Date of Hire

MonthDayYear
Social Security Number:*
Male Female
LVN/LPNRNARNP
Annual Salary Guesstimate*
Cell Number

Area CodePhone Number
Work Phone

Area CodePhone Number
E-Mail
Selection of Benefits
Short Term Disability Payable Up To 6 Months Per Claim

$2000 Monthly Tax Free Benefit $41 Biweekly$2500 Monthly Tax Free Benefit $50 Biweekly$3000 Monthly Tax Free Benefit $60 Biweekly$3500 Monthly Tax Free Benefit $70 Biweekly$4000 Monthly Tax Free Benefit $79 Biweekly$4500 Monthly Tax Free Benefit $89 Biweekly$5000 Monthly Tax Free Benefit $98 Biweekly$5500 Monthly Tax Free Benefit $108 Biweekly$6000 Monthly Tax Free Benefit $117 Biweekly
Short Term Disability Payable Up To 12 Months Per Claim

$2000 Monthly Tax Free Benefit $53 Biweekly$3000 Monthly Tax Free Benefit $79 Biweekly$3500 Monthly Tax Free Benefit $92 Biweekly$4000 Monthly Tax Free Benefit $105 Biweekly$4500 Monthly Tax Free Benefit $118 Biweekly$5000 Monthly Tax Free Benefit $131 Biweekly$5500 Monthly Tax Free Benefit $143 Biweekly$6000 Monthly Tax Free Benefit $156 Biweekly
Accident

Employee $12 BiweeklyEmployee & Spouse $16 BiweeklyEmployee & Children Under Age 26 $18 BiweeklyEmployee, Spouse & Children Under Age 26 $23 Biweekly
Hospital

Employee $24 BiweeklyEmployee & Spouse $40 BiweeklyEmployee & Children Under Age 26 $32 BiweeklyEmployee, Spouse & Children Under Age 26 $48 Biweekly
Critical Illness

Plan 1 $10,000Plan 2 $20,000Plan 3 $30,000Plan 4 $40,000For Biweekly Cost See Brochure PDF
Dependent Information

Only Populate If Adding Spouse & Dependent Children Age 26 And Younger
Name

First NameLast Name
Date of Birth

MonthDayYear
Relasonship
Name

First NameLast Name
Date of Birth

MonthDayYear
Relasonship
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Relasonship
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Relasonship
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Relasonship
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Relasonship
Mother Maiden Name For Signature*
Should be Empty:

Enrollment

Selection of Benefits

Dependent Information