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.

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* 1. Please enter your Employer's name:

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* 2. Date of hire

Date of Hire

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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:

Address

City

State

Zip

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* 6. Please select your gender:

Male

Female

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

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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:

Male

Female

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* 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