Below are the three Enrollment Options when an Employee can Enroll in the Dental and Vision Plans:

1. Open Enrollment:  August 1st - September 30th for a November 1st Effective Date
2. New Hire: First of the month following a 90 day Waiting Period
3. Special Enrollment: Must have a qualifying event

* 1. Please enter your Employer's Name

* 2. Employee First Name, MI, Last Name:

* 3. Your Social Security number:

* 4. Please enter your Street Address

* 5. Please select your gender:

* 6. Employee Date of Birth:

Date
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/

* 7. Please enter your phone number below:

* 8. Please enter your email address below:

* 9. Are you married or do you have a spouse?

* 10. Please enter the hours you work per week below:

* 11. Please enter your date of full-time hire below:

Date
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/
About Your Family:  Please include the names of the dependents you wish to enroll for coverage.

* 12. Spouse First Name, MI, Last Name:

* 13. Spouse Date of Birth:

Date
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/

* 14. Spouse's gender:

* 15. Child First Name, MI, Last Name:

* 16. Is the Child a Full Time Student

* 17. Child Date of Birth:

Date
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/

* 18. Child's gender:

* 19. Child First Name, MI, Last Name:

* 20. Is the Child a Full Time Student

* 21. Child Date of Birth:

Date
/
/

* 22. Child's gender:

* 23. Child First Name, MI, Last Name:

* 24. Is the Child a Full Time Student

* 25. Child Date of Birth:

Date
/
/

* 26. Child's gender:

* 27. Child First Name, MI, Last Name:

* 28. Is the Child a Full Time Student

* 29. Child Date of Birth:

Date
/
/

* 30. Child's gender:

* 31. Please elect the type of DENTAL coverage you want to elect:

  Employee Only Employee + Spouse Employee + Dependent/Child(ren) Employee + Spouse & Dependent/Child(ren)
Option 1  $1,000 Benefit
Option 2  $1,500 Benefit

* 32. Please select the type of VISION coverage you want to elect:

* 33. I DO NOT want to enroll in the Dental Plans?

* 34. I DO NOT want to enroll in the Vision Plan?

* 35. Please enter your name below as your electronic signature for coverage:

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