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
*
Cell Number
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
E-Mail Personal
Selection of Benefits
Standard Short Term Disability 6 Month Benefit Per Claim
Please Select
$2000 Monthly Benefit $41 Biweekly Premium
$2500 Monthly Benefit $50 Biweekly Premium
$3000 Monthly Benefit $60 Biweekly Premium
$3500 Monthly Benefit $70 Biweekly Premium
$4000 Monthly Benefit $79 Biweekly Premium
$4500 Monthly Benefit $89 Biweekly Premium
$5000 Monthly Benefit $98 Biweekly Premium
$5500 Monthly Benefit $108 Biweekly Premium
$6000 Monthly Benefit $117 Biweekly Premium
Standard Short Term Disability 12 Month Benefit Per Claim
Please Select
$2000 Monthly Benefit $53 Biweekly Premium
$2500 Monthly Benefit $67 Biweekly Premium
$3000 Monthly Benefit $79 Biweekly Premium
$3500 Monthly Benefit $92 Biweekly Premium
$4000 Monthly Benefit $105 Biweekly Premium
$4500 Monthly Benefit $118 Biweekly Premium
$5000 Monthly Benefit $131 Biweekly Premium
$5500 Monthly Benefit $143 Biweekly Premium
$6000 Monthly Benefit $156 Biweekly Premium
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.
Dependent Information
Only Populate If Adding Spouse & Dependent 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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