Name of company, DBA or sole proprietorship.

Important: Fields do not validate. Please enter date of birth using mm/dd/yyyy format. Please enter tax ID using xxx-xx-xxxx format. Use "+" button on right side to add additional dependents.

You may select one preventive health plan or membership plan option. See plan options.

You may select one preventive health plan or membership plan option. See plan options.

You may select one preventive health plan or membership plan option. See plan options.

You may select one preventive health plan or membership plan option. See plan options.

You may select one catastrophic plan. You have the choice of a $500 or $1,000 Initial Unshareable Amount (IUA). See plan options.

You may select one catastrophic plan. You have the choice of a $500 or $1,000 Initial Unshareable Amount (IUA). See plan options.

You may select one catastrophic plan. You have the choice of a $500 or $1,000 Initial Unshareable Amount (IUA). See plan options.

You may select one catastrophic plan. You have the choice of a $500 or $1,000 Initial Unshareable Amount (IUA). See plan options.

To register with the group health share (Sedera), a text message will be sent with your password. You will need to complete the registration process online or using your smart phone. See Sedera Registration Instructions.

Select your accident plan election. See accident plan to learn more.

Select your accident plan election. See accident plan to learn more.

Select your accident plan election. See accident plan to learn more.

Select your accident plan election. See accident plan to learn more.

Select your critical illness plan election. See critical illness page to learn more. See also rate sheet for rate details for corresponding coverage amounts and age.

By signing below, I affirm that the information above is correct and wish to enroll or waive as outlined above. I authorize the release of any medical information required to implement the plans selected. I also authorize the payroll deduction for any employee responsibility of the benefits selected.