Enroll Employee

1
Your Contact Information* This field is required.In case we have questions
Name
Email
2
Employer* This field is required.What is your company name?
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
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.
Month
Day
Year
5
Employee Basics* This field is required.Please tell us who this is
Employee Name
Employee Email
6
Employee Location* This field is required.Availability of some benefits is based on state of residence
7
Employment InformationLet us know relevant employment details
Employee Title
Scheduled Hours/Week
Salaried
Hourly
Payroll Status
Annual Wages (only required for compensation-based benefits, e.g., disability)
8
Additional CommentsAnything else you need to let us know about this enrollment?
9
Upload Forms or Supporting DocumentsOnly if needed
Drag and drop files here
Select files to upload
Cancelof
10
File(s) Uploaded?Log in to Jotform to securely retrieve uploaded files
Should be Empty: