Short Term Disability
Enrollment Form
Name
First Name
Last Name
Work Location City
Home Address
Street Address
City
State
Zip Code
Date of Birth
/
Month
/
Day
Year
Date of Hire
/
Month
/
Day
Year
Social Security Number:
*
Sex
Please Select
Male
Female
N/A
RN
NP
CRNA
Annual Salary Guesstimate
*
Cell Number
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
E-mail
Are you a dues paying union member of National Nurses United VA Medical Centers?
Yes
No
Selection of Benefits
Short Term Disability payment up to 6 months benefit per claim
$2000 Monthly Tax Free Benefit Cost $41 Biweekly
$2500 Monthly Tax Free Benefit Cost $50 Biweekly
$3000.Monthly Tax Free Benefit Cost $60 Biweekly
$3500 Monthly Tax Free Benefit Cost $70 Biweekly
$4000 Monthly Tax Free Benefit. Cost $79 Biweekly
$4500 Monthly Tax Free Benefit Cost $89 Biweekly
$5000 Monthly Tax Free Benefit. Cost $98 Biweekly
Short Term Disability payment up to 12 months benefit per claim
$2000 Monthly Tax Free Benefit Cost $51 Biweekly
$2500 Monthly Tax Free Benefit Cost $63 Biweekly
$3000 Monthly Tax Free Benefit Cost $75 Biweekly
$3500 Monthly Tax Free Benefit Cost $87 Biweekly
$4000 Monthly Tax Free Benefit Cost $99 Biweekly
$4500 Monthly Tax Free Benefit Cost $111 Biweekly
$5000 Monthly Tax Free Benefit Cost $123 Biweekly
Mother Maiden Name For Signature
*
Enroll
Should be Empty: