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 Select Age Group*Select the age group that you are in.Age 18-29Age 30-49Age 50-64Social 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 - $0Preventive HSA - $75 monthlyPreventive Advanced - $150 monthlySelect Base Health Plan - Employee & Spouse*You may select one preventive health plan or membership plan option. See plan options.Waive - $0Preventive HSA - $120 monthlyPreventive Advanced - $250 monthlySelect Base Health Plan - Employee & Child(ren)*You may select one preventive health plan or membership plan option. See plan options.Waive - $0Preventive HSA - $120 monthlyPreventive Advanced - $250 monthlySelect Base Health Plan - Family Rate*You may select one preventive health plan or membership plan option. See plan options.Waive - $0Preventive HSA - $150 monthlyPreventive Advanced - $350 monthlyHealth Savings Account (HSA) Contribution I would like to contribute funds to an Health Savings Account (HSA) managed by Optum Bank. Health Savings Account (HSA) Contribution Amount*The amount entered will be added to your Preventive HSA plan and deposited into your Health Savings Account (HSA) account. The account will be with Optum Bank. You will receive a debit card that will allow access to these funds for qualified medical expenses. Please enter a number from 1 to 583.Select Catastrophic Plan - Employee Rate*You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 18-29Waive - $0HealthShare @ $1,000 IUA - $150 monthlyHealthShare @ $2,500 IUA - $100 monthlyHealthShare @ $5,000 IUA - $75 monthlySelect Catastrophic Plan - Employee Rate*You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 30-49Waive - $0HealthShare @ $1,000 IUA - $175 monthlyHealthShare @ $2,500 IUA - $145 monthlyHealthShare @ $5,000 IUA - $125 monthlySelect Catastrophic Plan - Employee Rate*You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 50-64Waive - $0HealthShare @ $1,000 IUA - $225 monthlyHealthShare @ $2,500 IUA - $200 monthlyHealthShare @ $5,000 IUA - $150 monthlySelect Catastrophic Plan - Employee + Spouse*You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 18-29Waive - $0HealthShare @ $1,000 IUA - $300 monthlyHealthShare @ $2,500 IUA - $200 monthlyHealthShare @ $5,000 IUA - $150 monthlySelect Catastrophic Plan - Employee + Spouse*You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 30-49Waive - $0HealthShare @ $1,000 IUA - $350 monthlyHealthShare @ $2,500 IUA - $250 monthlyHealthShare @ $5,000 IUA - $225 monthlySelect Catastrophic Plan - Employee + Spouse*You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 50-64Waive - $0HealthShare @ $1,000 IUA - $450 monthlyHealthShare @ $2,500 IUA - $375 monthlyHealthShare @ $5,000 IUA - $300 monthlySelect Catastrophic Plan - Employee + Child(ren)*You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 18-29Waive - $0HealthShare @ $1,000 IUA - $300 monthlyHealthShare @ $2,500 IUA - $200 monthlyHealthShare @ $5,000 IUA - $150 monthlySelect Catastrophic Plan - Employee + Child(ren)*You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 30-49Waive - $0HealthShare @ $1,000 IUA - $350 monthlyHealthShare @ $2,500 IUA - $250 monthlyHealthShare @ $5,000 IUA - $225 monthlySelect Catastrophic Plan - Employee + Child(ren)*You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 50-64Waive - $0HealthShare @ $1,000 IUA - $450 monthlyHealthShare @ $2,500 IUA - $375 monthlyHealthShare @ $5,000 IUA - $300 monthlySelect Catastrophic Plan - Employee + Family*You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 18-29Waive - $0HealthShare @ $1,000 IUA - $450 monthlyHealthShare @ $2,500 IUA - $350 monthlyHealthShare @ $5,000 IUA - $250 monthlySelect Catastrophic Plan - Employee + Family*You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 30-49Waive - $0HealthShare @ $1,000 IUA - $500 monthlyHealthShare @ $2,500 IUA - $400 monthlyHealthShare @ $5,000 IUA - $350 monthlySelect Catastrophic Plan - Employee + Family*You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 50-64Waive - $0HealthShare @ $1,000 IUA - $700 monthlyHealthShare @ $2,500 IUA - $575 monthlyHealthShare @ $5,000 IUA - $450 monthlyDo 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. Medical Conditions Existing Prior to MembershipNeeds that result from a condition that existed prior to membership are only shareable if the condition is fully cured and 36 months have passed without any symptoms, treatment, or medication, even if the cause of the symptoms is unknown or misdiagnosed.Member NameConditionLast Treatment Date HealthShare Standards Of Health*By joining a HealthShare, you agree to live by the stands of good health. These standards include avoiding illegal drugs and excessive alcohol use. It is encouraged to try and maintain a healthy life style including exercise and proper nutrition. I agree to live by the HealthShare Standards of Health Select Dental Plan - Employee Rate*Select your dental plan election. See dental plan to learn more.Waive - $0Copay Plan - $25 monthlyPlus Plan - $35 monthlySelect Dental Plan - Employee & Spouse*Select your dental plan election. See dental plan to learn more.Waive - $0Copay Plan - $50 monthlyPlus Plan - $65 monthlySelect Dental Plan - Employee & Child(ren)*Select your dental plan election. See dental plan to learn more.Waive - $0Copay Plan - $50 monthlyPlus Plan - $75 monthlySelect Dental Plan - Family Rate*Select your dental plan election. See accident plan to learn more.Waive - $0Copay Plan - $75 monthlyPPO Plan - $115 monthlySelect Vision Plan - Employee Rate*Select your vision plan election. See vision plan to learn more.Waive - $0Vision Plan - $9 monthlySelect Vision Plan - Employee & Spouse*Select your vision plan election. See vision plan to learn more.Waive - $0Vision Plan - $15 monthlySelect Vision Plan - Employee & Child(ren)*Select your vision plan election. See vision plan to learn more.Waive - $0Vision Plan - $14 monthlySelect Vision Plan - Family Rate*Select your vision plan election. See vision plan to learn more.Waive - $0Vision Plan - $22 monthlyRequest 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.
