Healthiestyou Enrollment Application 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. * 1. Please enter your Employer's name: * 2. Date of hire Date of Hire MM / DD / YYYY * 3. Employee First, MI, Last Name: * 4. Your Social Security Number: * 5. Please enter your Street Address: Address City State Zip * 6. Please select your gender: Male Female * 7. Employee Date of Birth: Date MM / DD / YYYY * 8. Please enter your phone number: * 9. Please enter your email address: * 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 Health Employee Only Health Employee + Spouse Health Employee + Dependent/Child Health Employee + Family * 11. Spouse First, MI, Last Name: * 12. Spouse Date of Birth: * 13. Please select your Spouse gender: Male Female * 14. Please list all Enrolled Children First, MI, Last Name, Date of Birth and Gender: Child 1 Full Name Date of Birth and Gender Child 2 Full Name Date of Birth and Gender Child 3 Full Name Date of Birth and Gender Child 4 Full Name Date of Birth and Gender Child 5 Full Name Date of Birth and Gender Child 6 Full Name Date of Birth and Gender Done
