Employee Benefits Request Form

Employee Benefits Request Form

After you fill out this employee benefits request, we will contact you to go over details and open enrollment before the submission is sent to our 3rd party employee health group.
Date

MonthDayYear
Date
Employee Information
Name

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Has the employee been employed w/ agency 90 days or more?

YesNo
Dependent Information
Name of Dependent

First NameLast Name
Date of Birth of Beneficiary/Dependent

MonthDayYear
Date
Relationship to Employee/Principal
If not one's self is claiming
Type of coverage interest:
Are you requesting to cancel an "active" insurance plan?

YESNON/A
Details of Request
Enter the details
I hereby declare that the information I have provided above is true and correct, to the best of my knowledge. I understand that any false or willful dishonesty found to be in this request may cause the denial application. By signing this form, I bind myself legally bind myself in executing this request under the terms and conditions of my employment.
Signature of Employee

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