US Analytics

Employee Benefits Portal
Welcome to the {groupName} Benefits Enrollment System. Here, you will be able to enroll and submit changes to your benefits. Please click NEXT to continue.

Welcome!

What would you like to do?
What Type of Enrollment?*

Annual Open EnrollmentNew Employee Enrollment
Enter Last 4 Digits of Social Security Number

Demographic Information

Tell us about yourself!
Welcome {firstName} {lastName}!

We already have your demographic information on file. Click next to continue!
First Name
Last Name
First Name:*
Last Name:*
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Email*
example@example.com
Social Security Number*
Example: 123456789
Date of Hire*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Add Dependents

If you would like to add a spouse or children to any of the offered plans, please add them below. Once added, you will have the option to enroll them in coverage.
Please add a spouse or child(ren) below. If you do not wish to add any dependents to your plan(s), please click NEXT. If you do not add dependent(s) here, you will not be able to add them to any plans throughout this enrollment.
Spouse:
{spouseFirst} {spouseLast}
Add a Spouse?
Child(ren):
{child1} {child153}
{child2} {child255}
{child3} {child357}
{child4} {child459}
{child5} {child561}
{child6} {child663}
{child7} {child765}
Add Child(ren)?
Spouse First Name
Spouse Last Name
Child 1 First Name
Child 1 Last Name
Child 2 First Name
Child 2 Last Name
Child 3 First Name
Child 3 Last Name
Child 4 First Name
Child 4 Last Name
Child 5 First Name
Child 5 Last Name
Child 6 First Name
Child 6 Last Name
Child 7 First Name
Child 7 Last Name
Spouse Entered
Child Entered

Employer Paid Benefits

Your employer purchases the following coverage(s) at no cost to you. You will be automatically enrolled in the insurance plan(s) listed below.
{erPaid337} {erPaid315}

{erPaid338} {erPaid318}

{erPaid339} {erPaid321}

Medical Plan

Please make your medical plan selections below.
Current Med Cov Tier
Current Med Plan
Current Med Coverage - Reported
Current Med Plan - Reported
Current Medical Plan Selections

Current Medical Coverage: {currentMed44}
Current Medical Plan: {currentMed45}
Please select who you would like to enroll in the Medical Plan. You must enroll in coverage for yourself to be able to add dependent(s) to the plan.
Enroll Yourself In Medical Plan?*

YesNo
Enroll Spouse In Medical Plan?

YesNo
Enroll Child(ren) In Medical Plan?

YesNo
Which Medical Plan Do you Want to Enroll In?*

United Healthcare Medical Plan
Medical Plan Payroll Deduction: {perPay}
Med Cov Tier Value
Medical Coverage Tier
Medical Plan Selected
Monthly Med Ded
Per Pay Med Ded
Per Pay Med Ded - Calc
Med Summary
Med Change

Dental

Please make your dental selections below.
Current Dent Cov Tier
Current Dent Plan
Current Dent Coverage - Reported
Current Dent Plan - Reported
Current Dental Plan Selections

Current Dental Coverage: {currentDent95}
Current Dental Plan: {currentDent96}
Please select who you would like to enroll in the dental plan. You must enroll in coverage for yourself to be able to add dependent(s) to the plan.
Enroll Yourself In Dental Plan?*

YesNo
Enroll Spouse In Dental Plan?

YesNo
Enroll Child(ren) In Dental Plan?

YesNo
Which Dental Plan Do you Want to Enroll In?*

Principal PPO Dental Plan
Dental Payroll Deduction: {perPay112}

Below is a brief summary of your dental plan. For a full summary, click near the bottom of the chart.
	PPO Dental Plan
Insurance Carrier	Principal
Preventive Coverage	100%
Basic Coverage	80%
Major Coverage	50%
Annual Maximum	$1,500
Annual Deductible	$50 (applies to Basic & Major)

Dent Cov Tier Value
Dental Coverage Tier
Dental Plan Selected
Monthly Dent Ded
Per Pay Dent Ded
Per Pay Dent Ded - Calc
Dent Change
Dent Summary

Vision

Please make your Vision selections below.
Current Vis Cov Tier
Current Vis Plan
Current Vis Coverage - Reported
Current Vis Plan - Reported
Current Vision Plan Selections

Current Vision Coverage: {currentVis117}
Current Vision Plan: {currentVis118}
Please select who you would like to enroll in the vision plan. You must enroll in coverage for yourself to be able to add dependent(s) to the plan.
Enroll Yourself In Vision Plan?*

YesNo
Enroll Spouse In Vision Plan?

YesNo
Enroll Child(ren) In Vision Plan?

YesNo
Which Vision Plan Do you Want to Enroll In?*

Principal VSP Vision Plan
Vision Payroll Deduction: {perPay134}

Below is a brief summary of your vision plan. For a full summary, click near the bottom of the chart.
	Vision Plan
Insurance Carrier	Principal
Vision Network	VSP
Vision Exam	$10 Copay (once per 12 mos.)
Lenses	$25 Copay (once per 12 mos.)
Frames	$0 Copay w/ $130 Allowance (once per 12 mos.)
Contact Lenses	$130 Allowance (once per 12 mos.)

Vis Cov Tier Value
Vision Coverage Tier
Vision Plan Selected
Monthly Vis Ded
Per Pay Vis Ded
Per Pay Vis Ded - Calc
Vis Summary
Vis Change

New Employee Voluntary Life
Employee Voluntary Life Limits
Minimum Amount: {eeMinimum154}
Maximum Amount: {eeMaximum}
Maximum Guarantee Issue Amount: {eeMaximum156}*
*if you elect more than the Guarantee Issue Maximum, you must fill out a medical history questionnaire.
Enroll Yourself In Voluntary Life Plan?*

YesNo
Your Age Bracket*
Select Employee Voluntary Life Amount*
You have elected more than the Guarantee Issue Maximum amount of {eeMaximum156}. You will be automatically emailed a health questionnaire to fill out. Once completed and submitted, you will be notified if you qualify for the selected amount. If not, you will receive the Guarantee Issue Maximum amount of {eeMaximum156}.
Employee Voluntary Life Amount: {eeVol}
Employee Voluntary Life Payroll Deduction: {perPay160}
EE Vol Life Amt
EE Vol Life Amount #
Monthly EE Vol Life Ded
Per Pay EE Vol Life Ded
Per Pay EE Vol Life Ded - Calc
New EE VTL Summary
New EOI Trigger

Current Employee Voluntary Life
Current EE Vol Life
Current EE Vol Life - Calc
Curr EE Max EE Life1
Curr EE Max EE Life-Calc
Current Employee Voluntary Life Amount

Current Life Amount: {currentEe204}
Employee Voluntary Life Limits
Minimum Amount: {eeMinimum154}
Maximum Amount: {eeMaximum}
Maximum Guarantee Issue Amount: {currEe227}*
*if you elect more than the Guarantee Issue Maximum, you must fill out a medical history questionnaire.
Enroll Yourself In Voluntary Life Plan?*

YesNo
Because you are enrolling for the 1st time, you will be required to fill out a medical questionnaire to make sure you qualify for coverage. This questionnaire will be automatically emailed to you once you complete enrollment.
Change Employee Voluntary Life Amount?*

YesNo
You may increase your voluntary life amount by {oeMax} without answering medical questions. If you would like to increase your amount by more than {oeMax}, you must fill out a medical questionnaire that will be automatically emailed to you once you complete enrollment.
Your Age Bracket:*
Select New Employee Voluntary Life Amount*
You have elected more than the Guarantee Issue Maximum amount of {currEe227}. You will be automatically emailed a health questionnaire to fill out. Once completed and submitted, you will be notified if you qualify for the selected amount. If not, you will receive the Guarantee Issue Maximum amount of {currEe227}.
Employee Voluntary Life Amount: {newEe}
Employee Voluntary Life Payroll Deduction: {newPer}
New EE Vol Life Amt
New EE Vol Life Amount #
New Monthly EE Vol Life Ded
New Per Pay EE Vol Life Ded
New Per Pay EE Vol Life Ded - Calc
Curr EE VTL Summary
Curr EOI Trigger1
Curr EOI Trigger2

Spouse Voluntary Life
Spouse Voluntary Life Limits
Minimum Amount: {spMinimum186}
Maximum Amount: {sp2} of chosen employee amount ({spMaximum})
Maximum Guarantee Issue Amount: {spMaximum187}*
*if you elect more than the Guarantee Issue Maximum, you must fill out a medical history questionnaire.
Enroll Your Spouse In Voluntary Life Plan?*

YesNo
Select Spouse Voluntary Life Amount*
You have exceded the spouse maximum of {spMaximum}! Please correct!
You have elected more than the Guarantee Issue Maximum amount of {spMaximum187}. You will be automatically emailed a health questionnaire to fill out. Once completed and submitted, you will be notified if you qualify for the selected amount. If not, you will receive the Guarantee Issue Maximum amount of {spMaximum187}.
Spouse Life Amount: {spVol}
Spouse Voluntary Life Payroll Deduction: {perPay180}
SP Vol Life Amt
SP Vol Life Amount #
Monthly SP Vol Life Ded
Per Pay SP Vol Life Ded
Per Pay SP Vol Life Ded - Calc
New SP VTL Summary
New SP EOI Trigger

Current Employee Spouse Voluntary Life
Current SP Vol Life
Current SP Vol Life - Calc
Curr SP Max SP Life1
Curr SP Max SP Life-Calc
Curr SP Max
Curr SP Max#
Adj SP VL Max
Adj SP VL Max - Calc
Current Spouse Voluntary Life Amount

Current Spouse Life Amount: {currentSp231}
Spouse Voluntary Life Limits
Minimum Amount: {spMinimum186}
Maximum Amount: {sp2} of chosen employee amount ({currSp253})
Maximum Guarantee Issue Amount: {adjSp255}*
*if you elect more than the Guarantee Issue Maximum, you must fill out a medical history questionnaire.
Enroll Your Spouse In Voluntary Life Plan?*

YesNo
Because you are enrolling for the 1st time, you will be required to fill out a medical questionnaire to make sure you qualify for coverage. This questionnaire will be automatically emailed to you once you complete enrollment.
Change Spouse Voluntary Life Amount?*

YesNo
You may increase your voluntary life amount by {spOe252} without answering medical questions. If you would like to increase your amount by more than {spOe252}, you must fill out a medical questionnaire that will be automatically emailed to you once you complete enrollment.
Select New Spouse Voluntary Life Amount*
You have exceded the spouse maximum of {currSp253}! Please correct!
You have elected more than the Guarantee Issue Maximum amount of {adjSp255}. You will be automatically emailed a health questionnaire to fill out. Once completed and submitted, you will be notified if you qualify for the selected amount. If not, you will receive the Guarantee Issue Maximum amount of {adjSp255}.
Spouse Voluntary Life Amount: {newSp}
Spouse Voluntary Life Payroll Deduction: {newPer249}
New SP Vol Life Amt
New SP Vol Life Amount #
New Monthly SP Vol Life Ded
New Per Pay SP Vol Life Ded
New Per Pay SP Vol Life Ded - Calc
CurrSP VTL Summary
Curr SP EOI Trigger1
Curr SP EOI Trigger2

Child Voluntary Life
Current CH Vol Life
Current CH Vol Life - Calc
CH Vol Life - Calc
Current Child(ren) Voluntary Life Amount

Current Child(ren) Life Amount: {currentCh258}
Coverage is per family regardless of how many children you have.
Enroll Child(ren) In Voluntary Life?*

YesNo
Change Child(ren) Voluntary Life Amount?*

YesNo
You have not added your child(ren) to your profile. If you would like to enroll your child(ren), please go back to the Add Dependent section and enter child(ren) information.
Please Select Child Life Option*

Cancel Child Voluntary Life$10,000
Child(ren) Voluntary Life Amount: {pleaseSelect}
Child(ren) Voluntary Life Payroll Deduction: {newPer263}
New Monthly CH Vol Life Ded
New Per Pay CH Vol Life Ded
New Per Pay CH Vol Life Ded - Calc
CH VTL Summary
CH Vol Life Appear
CH Vol Life Appear2
CH Vol Life Appear3

Voluntary Short-Term Disability
Current Vol STD
Annual Salary
Annual Salary#
Annual Salary STD
Current Short-Term Disability Election

Short-Term Disability: {currentVol}
Enroll In Short-Term Disability?*

YesNo
Annual Salary:*
Your Age Bracket:*
Do You Want To Cancel Short-Term Disability?*

YesNo
Short-Term Disability Payroll Deduction: {stdPer}
Short-Term Disability Payroll Deduction: $0.00
STD Monthly Ded
STD Enroll Status
STD Per Pay Ded
STD Per Pay Ded - Calc
STD Summary
STD Email Adjust
STD Rate Factor

Voluntary Long-Term Disability
Current Vol LTD
Annual Salary
Annual Salary LTD#
Annual Salary LTD
Current Long-Term Disability Election

Long-Term Disability: {currentVol289}
Enroll In Long-Term Disability?*

YesNo
Annual Salary:*
Your Age Bracket:*
Do You Want To Cancel Long-Term Disability?*

YesNo
Long-Term Disability Payroll Deduction: {ltdPer}
Long-Term Disability Payroll Deduction: $0.00
LTD Monthly Ded
LTD Per Pay Ded
LTD Enroll Status
LTD Per Pay Ded - Calc
LTD Summary
LTD Email Adjust

Summary

{erPaid337} {erPaid354}

{erPaid338} {erPaid355}

{erPaid339} {erPaid356}
Total Per Pay Ded
Total Per Pay Period Deduction: {totalPer}

Signature
Employee Acknowledgement*

I understand that the selection I have just made may result in premium deductions from my paycheck. I also understand that the choices I have made here may not be changed until next open enrollment or a qualifying event occurs.
Signature (please type full name)*
Should be Empty:

{medTag}	{medicalPlan}	{medicalCoverage}	{perPay}
{dentTag}	{dentalPlan}	{dentalCoverage}	{perPay112}
{visTag}	{visionPlan}	{visionCoverage}	{perPay134}
{eeVol332}	{eeVol}		{perPay160}
{spVol333}	{spVol}		{perPay180}
{chVol334}	{pleaseSelect}		{newPer263}

{medTag}	{medicalPlan}	{medicalCoverage}	{perPay}
{dentTag}	{dentalPlan}	{dentalCoverage}	{perPay112}
{visTag}	{visionPlan}	{visionCoverage}	{perPay134}
{eeVol332}	{newEe}		{newPer}
{spVol333}	{newSp}		{newPer249}
{chVol334}	{pleaseSelect}		{newPer263}

Employee Benefits Portal

Agent Set Up

Welcome!

Demographic Information

Add Dependents

Employer Paid Benefits

Medical Plan

Dental

Vision

New Employee Voluntary Life

Current Employee Voluntary Life

Spouse Voluntary Life

Current Employee Spouse Voluntary Life

Child Voluntary Life

Voluntary Short-Term Disability

Voluntary Long-Term Disability

Summary

Signature