World Subs East Hawaii

SUBSCRIBER ENROLLMENT FORM

Please be sure application is completed in full to ensure proper enrollment.
Please Select your Restaurant Location

EMPLOYER SECTION
Point of Contact
Phone Number
Fax Number
Email
example@example.com
HMSA Group
HMSA Band

Type of Enrollment
Type of Enrollment (select one)
Specify Qualifying Event
Upload Qualifying Event Documentation

Acceptable Documents: Loss of Other Coverage Letter, Marriage License, Divorce Decree, Birth Record, Death Certificate. You can scan or take a photo of the document and upload the file here.
Cancelof
Enter Effective Date of Coverage

MonthDayYear
Health Plans only begin on the 1st of the month. Ask your employer for your effective date of coverage.

PLAN SELECTION

ACA SHOP AGE-RATED PLANS
Select Insurance Carrier
What Kind of Health Plan Are You Looking For?

PLAN SELECTION

Select 1 Plan from the following Age-Rated Health Plans your Employer is offering.
Available Full-Package HMSA Plans
Available Medical & Drug HMSA Package
Available Rider Plan (Dental, Vision, Group Life ONLY)

Enroll Dependent(s)

Enroll your spouse and/or child(ren)
Dependent Type
Dependent Name
First Name, MI, Last Name
Dependent Sex
Dependent Date of Birth

MonthDayYear
Date
Dependent Social Security Number
Dependent Primary Care Provider (PCP)
First Name and Last Name
Current PCP?

Do You Need to Add More Dependents?

Enroll Dependent(s)

Enroll your spouse and/or child(ren)
Dependent Type
Dependent Name
First Name, MI, Last Name
Dependent Sex
Dependent Date of Birth

MonthDayYear
Date
Dependent Social Security Number
Dependent Primary Care Provider (PCP)
First Name and Last Name
Current PCP?

Do You Need to Add More Dependents?

Enroll Dependent(s)

Enroll your spouse and/or child(ren)
Dependent Type
Dependent Name
First Name, MI, Last Name
Dependent Sex
Dependent Date of Birth

MonthDayYear
Date
Dependent Social Security Number
Dependent Primary Care Provider (PCP)
First Name and Last Name
Current PCP?

Do You Need to Add More Dependents?

Enroll Dependent(s)

Enroll your spouse and/or child(ren)
Dependent Type
Dependent Name
First Name, MI, Last Name
Dependent Sex
Dependent Date of Birth

MonthDayYear
Date
Dependent Social Security Number
Dependent Primary Care Provider (PCP)
First Name and Last Name
Current PCP?

Do You Need to Add More Dependents?

Enroll Dependent(s)

Enroll your spouse and/or child(ren)
Dependent Type
Dependent Name
First Name, MI, Last Name
Dependent Sex
Dependent Date of Birth

MonthDayYear
Date
Dependent Social Security Number
Dependent Primary Care Provider (PCP)
First Name and Last Name
Current PCP?

Do You Need to Add More Dependents?

Enroll Dependent(s)

Enroll your spouse and/or child(ren)
Dependent Type
Dependent Name
First Name, MI, Last Name
Dependent Sex
Dependent Date of Birth

MonthDayYear
Date
Dependent Social Security Number
Dependent Primary Care Provider (PCP)
First Name and Last Name
Current PCP?

Coordination of Benefits

Other Insurance Coverage
Do you or someone else covered under this insurance policy have other insurance coverage at the same time this policy is in effect?

Coordination of Benefits

Other Insurance Coverage
Name of Health Plan
Name of Plan Holder
Health Plan Number
Effective Date of Coverage

MonthDayYear
Date

Authorization
You agree that the information you entered on this enrollment is true and accurate. Enrollment into the plan you selected is subject to the approval of your employer.
Your Signature
Before you submit this Enrollment Form, please review your information you entered by clicking the "Preview PDF" button below. If you need to make corrections, use the "Back" button and make any corrections. If the information entered is correct, hit "Submit" and you're done
Should be Empty: