Employee Registration Form

  • Employee Registration Form

  • This form allows you to add yourself, plus up to 6 dependents. If you require more dependents, please call or email our office:

    groups@assurancehealth.org

    509-823-4650

  • Employee Information

    This is who is employed by the company you've already mentioned. You'll enter family members (if any) later.
  • Employee Gender*
  • When would you like to start membership?*
     - -
  • What's your Date of Birth?*
     - -
  • Format: (000) 000-0000.
  • Is the above number a mobile or home phone?*
  • How many dependents would you like to register (spouse and/or children)?*
  • Gender
  • Date of Birth
     - -
  • Dependent's relationship to the employee...
  • Format: (000) 000-0000.
  • Gender
  • Date of Birth
     - -
  • Dependent's relationship to the employee...
  • Format: (000) 000-0000.
  • Gender
  • Date of Birth
     - -
  • Dependent's relationship to the employee...
  • Format: (000) 000-0000.
  • Gender
  • Date of Birth
     - -
  • Dependent's relationship to the employee...
  • Format: (000) 000-0000.
  • Gender
  • Date of Birth
     - -
  • Dependent's relationship to the employee...
  • Format: (000) 000-0000.
  • Gender
  • Date of Birth
     - -
  • Dependent's relationship to the employee...
  • Format: (000) 000-0000.

  • Great! All done

    Click submit below, and we'll get working on your registration!
  • Should be Empty: