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
Other
4
Employee Basics* This field is required.Please tell us about the newly eligible employee.
Employee Name
Employee Email
Employee mobile phone number (if no email available)
5
Qualifying Event Date* This field is required.Please provide date of hire or increase in hours.
Do not use coverage effective date; plan rules will calculate based on QE date.
Month
Day
Year
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
Original Date of Hire (if this is an increase in hours QLE)
Please Select
Please Select
Salaried
Hourly
Payroll Status
Annual Wages (required if life/disability coverage if offered)
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: