Employee Enrollment To Existing Group Step 1 of 2 0% Company InformationCompany Name*Name of company, DBA or sole proprietorship.Company Contact Name First Last Company Contact Email* Employee InformationName* First MI Last Additional Name Details Prefix Mr.Mrs.MissMs.Dr.Prof.Rev. Suffix Date of Birth MM DD YYYY Social Security Number or Tax ID*GenderMaleFemaleAddress Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email PhoneCoverage TypeEmployee OnlyEmployee & SpouseEmployee & Child(ren)FamilySpouse Name First Middle Last Spouse Tax ID*Spouse DOB MM DD YYYY Spouse GenderMaleFemaleDependents*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.First NameLast NameDate of BirthTax IDM/F Enrollment Plan Selection Select the plans that you wish to offer or enroll in. Additional setup may be required for some plan types.Select Base Health Plan - Employe Rate*You may select one preventive health plan or membership plan option. See plan options.Waive - $0TelaDoc Membership - $10 monthlyASO MEC - $30 monthlyPreventive Basic - $80 monthlyPreventive Advanced - $150 monthlySelect Base Health Plan - Employee & Spouse*You may select one preventive health plan or membership plan option. See plan options.Waive - $0TelaDoc Membership - $10 monthlyASO MEC - $55 monthlyPreventive Basic - $110 monthlyPreventive Advanced - $240 monthlySelect Base Health Plan - Employee & Child(ren)*You may select one preventive health plan or membership plan option. See plan options.Waive - $0TelaDoc Membership - $10 monthlyASO MEC - $55 monthlyPreventive Basic - $110 monthlyPreventive Advanced - $240 monthlySelect Base Health Plan - Family Rate*You may select one preventive health plan or membership plan option. See plan options.Waive - $0TelaDoc Membership - $10 monthlyASO MEC - $80 monthlyPreventive Basic - $150 monthlyPreventive Advanced - $325 monthlySelect Catastrophic Plan - Employee Rate*You may select one catastrophic plan. You have the choice of a $500 or $1,000 Initial Unshareable Amount (IUA). See plan options.Waive - $0Health Share @ $1,000 IUA - $166 monthlyHealth Share @ $1,000 IUA - $133 monthly (under age 30)Select Catastrophic Plan - Employee + Spouse*You may select one catastrophic plan. You have the choice of a $500 or $1,000 Initial Unshareable Amount (IUA). See plan options.Waive - $0Health Share @ $1,000 IUA - $386 monthlyHealth Share @ $1,000 IUA - $341 monthly (under age 30)Select Catastrophic Plan - Employee + Child(ren)*You may select one catastrophic plan. You have the choice of a $500 or $1,000 Initial Unshareable Amount (IUA). See plan options.Waive - $0Health Share @ $1,000 IUA - $328 monthlyHealth Share @ $1,000 IUA - $279 monthly (under age 30)Select Catastrophic Plan - Family Rate*You may select one catastrophic plan. You have the choice of a $500 or $1,000 Initial Unshareable Amount (IUA). See plan options.Waive - $0Health Share @ $1,000 IUA - $520 monthlyHealth Share @ $1,000 IUA - $468 monthly (under age 30)Group Health Share Setup Requirement - Cell Phone Number*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.Do you use tobacco products?Sedera (group health share) charges an additional $45 monthly fee for tobacco users. You should select yes if you have used tobacco products in the last 12 months. Yes, I use tobacco products. Select Dental Plan - Employee Rate*Select your dental plan election. See dental plan to learn more.Waive - $0Copay Plan - $20.27 monthlyPPO Plan - $36.65 monthlySelect Dental Plan - Employee & Spouse*Select your dental plan election. See dental plan to learn more.Waive - $0Copay Plan - $36.25 monthlyPPO Plan - $67.38 monthlySelect Dental Plan - Employee & Child(ren)*Select your dental plan election. See dental plan to learn more.Waive - $0Copay Plan - $41.60 monthlyPPO Plan - $85.11 monthlySelect Dental Plan - Family Rate*Select your dental plan election. See accident plan to learn more.Waive - $0Copay Plan - $53.13 monthlyPPO Plan - $109.50 monthlySelect Vision Plan - Employee Rate*Select your vision plan election. See vision plan to learn more.Waive - $0Vision Plan - $8.42 monthlySelect Vision Plan - Employee & Spouse*Select your vision plan election. See vision plan to learn more.Waive - $0Vision Plan - $14.61 monthlySelect Vision Plan - Employee & Child(ren)*Select your vision plan election. See vision plan to learn more.Waive - $0Vision Plan - $13.58 monthlySelect Vision Plan - Family Rate*Select your vision plan election. See vision plan to learn more.Waive - $0Vision Plan - $20.45 monthlySelect Accident Plan - Employee Rate*Select your accident plan election. See accident plan to learn more.Waive - $0Accident Plan, Level 2 - $26.80 monthlySelect Accident Plan - Employee & Spouse*Select your accident plan election. See accident plan to learn more.Waive - $0Accident Plan, Level 2 - $36.00 monthlySelect Accident Plan - Employee & Child(ren)*Select your accident plan election. See accident plan to learn more.Waive - $0Accident Plan, Level 2 - $36.60 monthlySelect Accident Plan - Family Rate*Select your accident plan election. See accident plan to learn more.Waive - $0Accident Plan, Level 2 - $48.40 monthlySelect Critical Illness Plan*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.Waive - $0Plan A, $10,000 benefit levelPlan A, $20,000 benefit levelPlan A, $30,000 benefit levelPlan A, $40,000 benefit levelPlan A, $50,000 benefit levelPlan A, $60,000 benefit levelPlan A, $70,000 benefit levelRequest Effective MonthEffective dates are the first of the selected month. We try to accommodate requested effective dates the best we can though there are sometimes limitations with the carrier providing coverage. We cannot back date coverage.JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberSignature*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.
