MightyWELL Employee Enrollment Form

MightyWELL Health Employee Enrollment

Affordable, Flexible, Transparent, Robust
Primary Applicant Name*

First NameMiddle NameLast NameSuffix
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number*
Date of Birth*
Gender *
Tobacco User?*

YesNo
Plan and Membership Start Date*
Date
Employer or Company Name:*

MightyWELL Representative
Representative Name

FirstLast
Phone Number
Email
example@example.com
Applicant Signature
Signature*

Clear
Date*

MonthDayYear
Date
Be certain to preview your application and download a copy for your records as its likely to be needed for future reference*

Acknowledge
Should be Empty:

	YES	NO
1. In the past 24 months, has any individual to be enrolled been examined, diagnosed or treated for any illness, disease or injury?
2. In the past 24 months has any individual to be enrolled experienced illness, disease or an accident SYMPTOM that is likely or may require medical treatment?
3. In the past 36 months, has any individual to be enrolled received treatment for alcohol or drug abuse?
4. Are all individuals to be enrolled ages 19-26 employed or a full time student in an accredited school or college?
5. In the past 24 months, has any individual to be enrolled engaged in hazardous sport or activities including organized racing, parachuting, rodeo riding, motorcycling, mountain climbing, or scuba diving or plan to do so?

MightyWELL Health Employee Enrollment