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
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Area Code
Phone Number
E-Mail Personal
Selection of Benefits
Manhattan Life Short Term Disability 6 Month Benefit Per Claim
Please Select
$600
$700
$800
$900
$1000
$1100
$1200
$1300
$1400
$1500
$1600
$1700
$1700
$1800
$1900
$2000
$2100
$2200
$2300
$2400
$2500
$2600
$2700
$2800
$2900
$3000
$3100
$3200
$3300
$3400
$3500
$3600
$3700
$3800
$3900
$4000
$4100
$4200
$4300
$4400
$4500
$4600
$4700
$4800
$4900
$5000
For Biweekly Premiums Download PDF
Manhattan Life Short Term Disability 12 Month Benefit Per Claim
Please Select
$600
$700
$800
$900
$1000
$1100
$1200
$1300
$1400
$1500
$1600
$1700
$1800
$1900
$2000
$2100
$2200
$2300
$2400
$2500
$2600
$2700
$2800
$2900
$3000
$3100
$3200
$3300
$3400
$3500
$3600
$3700
$3800
$3900
$4000
$4100
$4200
$4300
$4400
$4500
$4600
$4700
$4800
$4900
$5000
For Biweekly Premiums Download PDF
Aflac Cancer
Employee $28 Biweekly Premium
Employee & Spouse $48 Biweekly Premium
Employee & Children Under Age 26 $28 Biweekly Premium
Employee, Spouse & Children Under Age 26 $48 Biweekly Premium
Coverage cost and benefits may vary by state.
Will email for 5 simple health questions about any history of cancer.
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
I will email you for beneficiary and a few simple health questions for face amount of coverage. For Biweekly Premiums Download PDF
MassMutual Whole Life Insurance Spouse
Please Select
$25,000
$50,000
You will be the beneficiary and will email for a few simple health questions about your spouse for face amount of coverage. For Biweekly Premiums Download PDF
MassMutual Whole Life Insurance Children & Grandchildren Age 26 And Younger
Please Select
$25,000
$50,000
You will be the beneficiary. For Biweekly Premiums Download PDF
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
*
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