Voluntary Weekly Premiums  (Based on a 48 week pay cycle)

Employee: $2.75      Family: $3.75

An Employee can enroll at anytime with a first of the month effective date after submitting their application.

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* 1. Please enter your Employer's name:

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* 2. Date of hire

Date

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* 3. Employee First, MI, Last Name:

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* 4. Your Social Security Number:

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* 5. Please enter your Street Address:

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* 6. Please select your gender:

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* 7. Employee Date of Birth:

Date

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* 8. Please enter your phone number:

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* 9. Please enter your email address:

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* 10. Select the type of Healthiestyou coverage in which you wish to enroll (child up to age 26):

  Employee Only Employee + Spouse Employee + Dependent/Child Employee + Family
Health

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* 11. Spouse First, MI, Last Name:

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* 12. Spouse Date of Birth:

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* 13. Please select your Spouse gender:

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* 14. Please list all Enrolled Children First, MI, Last Name, Date of Birth and Gender:

T