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
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/

* 3. Employee First, MI, Last Name:

* 4. Your Social Security Number:

* 5. Please enter your Street Address:

* 6. Please select your gender:

* 7. Employee Date of Birth:

Date
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/

* 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

* 11. Spouse First, MI, Last Name:

* 12. Spouse Date of Birth:

* 13. Please select your Spouse gender:

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

T