Confidential Employee Data Form
Company Name:
*
Primary Contact Name
*
First Name
Last Name
Primary Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Coverage Options:
*
Extended Health
Dental
Long Term Disability
Critical Illness
Health Spending Account
Employee Assistance Program
How Many Full Time Employees are you looking to provide coverage for?
Employee Name:
Date of Birth:
-
Month
-
Day
Year
Sex
Male
Female
Type of Coverage (Choose 1)
Single (just you)
Couple (you and a partner)
Family (you, a partner and dependent children under 21)
Want to add a second employee?
*
Yes please!
No thanks, we are all done!
Back
Next
Employee Name:
Date of Birth:
-
Month
-
Day
Year
Sex
Male
Female
Type of Coverage (Choose 1)
Single (just you)
Couple (you and a partner)
Family (you, a partner and dependent children under 21)
Want to add a third employee?
*
Yes please!
No thanks, we are all done!
Back
Next
Employee Name:
Date of Birth:
-
Month
-
Day
Year
Sex
Male
Female
Type of Coverage (Choose 1)
Single (just you)
Couple (you and a partner)
Family (you, a partner and dependent children under 21)
Want to add a fourth employee?
*
Yes please!
No thanks, we are all done!
Back
Next
Employee Name:
Date of Birth:
-
Month
-
Day
Year
Sex
Male
Female
Type of Coverage (Choose 1)
Single (just you)
Couple (you and a partner)
Family (you, a partner and dependent children under 21)
Want to add a fifth employee?
*
Yes please!
No thanks, we are all done!
Back
Next
Employee Name:
Date of Birth:
-
Month
-
Day
Year
Sex
Male
Female
Type of Coverage (Choose 1)
Single (just you)
Couple (you and a partner)
Family (you, a partner and dependent children under 21)
Want to add a sixth employee?
*
Yes please!
No thanks, we are all done!
Back
Next
Employee Name:
Date of Birth:
-
Month
-
Day
Year
Sex
Male
Female
Type of Coverage (Choose 1)
Single (just you)
Couple (you and a partner)
Family (you, a partner and dependent children under 21)
Want to add a seventh employee?
*
Yes please!
No thanks, we are all done!
Back
Next
Employee Name:
Date of Birth:
-
Month
-
Day
Year
Sex
Male
Female
Type of Coverage (Choose 1)
Single (just you)
Couple (you and a partner)
Family (you, a partner and dependent children under 21)
Want to add an eighth employee?
*
Yes please!
No thanks, we are all done!
Back
Next
Employee Name:
Date of Birth:
-
Month
-
Day
Year
Sex
Male
Female
Type of Coverage (Choose 1)
Single (just you)
Couple (you and a partner)
Family (you, a partner and dependent children under 21)
Want to add a ninth employee?
*
Yes please!
No thanks, we are all done!
Back
Next
Employee Name:
Date of Birth:
-
Month
-
Day
Year
Sex
Male
Female
Type of Coverage (Choose 1)
Single (just you)
Couple (you and a partner)
Family (you, a partner and dependent children under 21)
Want to add a tenth employee?
*
Yes please!
No thanks, we are all done!
Back
Next
Employee Name:
Date of Birth:
-
Month
-
Day
Year
Sex
Male
Female
Type of Coverage (Choose 1)
Single (just you)
Couple (you and a partner)
Family (you, a partner and dependent children under 21)
Want to add an eleventh employee?
*
Yes please!
No thanks, we are all done!
Back
Next
Employee Name:
Date of Birth:
-
Month
-
Day
Year
Sex
Male
Female
Type of Coverage (Choose 1)
Single (just you)
Couple (you and a partner)
Family (you, a partner and dependent children under 21)
Want to add a twelfth employee?
*
Yes please!
No thanks, we are all done!
Back
Next
Employee Name:
Date of Birth:
-
Month
-
Day
Year
Sex
Male
Female
Type of Coverage (Choose 1)
Single (just you)
Couple (you and a partner)
Family (you, a partner and dependent children under 21)
Want to add a thirteenth employee?
*
Yes please!
No thanks, we are all done!
Back
Next
Employee Name:
Date of Birth:
-
Month
-
Day
Year
Sex
Male
Female
Type of Coverage (Choose 1)
Single (just you)
Couple (you and a partner)
Family (you, a partner and dependent children under 21)
Want to add a fourteenth employee?
*
Yes please!
No thanks, we are all done!
Back
Next
Employee Name:
Date of Birth:
-
Month
-
Day
Year
Sex
Male
Female
Type of Coverage (Choose 1)
Single (just you)
Couple (you and a partner)
Family (you, a partner and dependent children under 21)
Want to add a fifteenth employee?
*
Yes please!
No thanks, we are all done!
Back
Next
Employee Name:
Date of Birth:
-
Month
-
Day
Year
Sex
Male
Female
Type of Coverage (Choose 1)
Single (just you)
Couple (you and a partner)
Family (you, a partner and dependent children under 21)
Back
Next
Any additional comments or information you want to share with us?
Submit
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