Enroll Employee

1
Your Contact Information* This field is required.In case we have questions
Name
Email
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2
Employer* This field is required.What is your company name?
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3
Reason for Enrollment* This field is required.Let us know the relevant qualifying event
New hire
Increase in work hours
Loss of other group coverage
Open enrollment
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4
Qualifying Event Date* This field is required.Please provide date of hire, or last date of other coverage for qualifying events
Do not use coverage effective date; plan rules will calculate based on QE date.
Year
Month
Day
Do not use coverage effective date; plan rules will calculate based on QE date.
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5
Employee Basics* This field is required.Please tell us who this is
Employee Name
Employee Email
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6
Employee Location* This field is required.Availability of some benefits is based on state of residence
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7
Employment InformationLet us know relevant employment details
Employee Title
Scheduled Hours/Week
Payroll Status
Annual Wages (only required for compensation-based benefits, e.g., disability)
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8
Additional CommentsAnything else you need to let us know about this enrollment?
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9
Upload Forms or Supporting DocumentsOnly if needed
Drag and drop files here
Select files to upload
Browse Files
Cancelof
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10
File(s) Uploaded?Log in to Jotform to securely retrieve uploaded files
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