WorkingAmericanBenefits™

                                                                  ENROLLMENT  FORM            

To enroll in group insurance from the companies listed with WorkingAmericanBenefits, you are required to complete this form with your personal information.  For your comfort, you may review our Privacy Policy regarding the treatment of your personal information.  Your information is mandatory.  Without it we cannot complete your application for insurance.  Once we have collected your information, we will turn it over to our professional insurance agents/Enrollers who will complete your insurance application(s).  You will be contacted by a professional insurance agent and/or your Human Resource Department.  Your insurance agent or Human Resource Representative will answer your questions about specific insurance products, and provide you with additional information  or product material as needed.   Note:  If you do not wish to speak to our professional agents when you are contacted, please convey this information to your Human Resource Department.  Thank you.

Note: Complete and submit this form for each employee (and his/her dependents) to be insured.

                                                               
Product Selection:

      

 

    Health Insurance                                 Company                                       Deductible/CoIns     

    Limited Medical Plan          

 

Eligible Employee's Information: (Required)

First Name:       *           MI:            Last Name: *    

Street Address:*     Apt. or Suite No.:     

City:                    *             State:*            Zip Code:* 

Last 4 of Soc Sec No.:*    Home Phone.: *   Work Phone:* 

Date Of Birth:    *   Male   Female

 

Enter information of employer or company responsible for List Billing, or Payroll Deduction:

Employer/Co. Name:            Payroll Deduction?  Yes  No

Employer/Co. Address: 

Occupation/Duties:    Date Employed:  

Hours Wrkd./Week:    Employee No.:         Department/Section No.: 

Other person(s) to be insured Information: 

Note: Enter all that applies.

 

Dependents:  

 

                 

1) First Name:              MI:            Last Name:     

    Relationship:    Date Of Birth:    Male   Female

2) First Name:              MI:            Last Name:     

    Relationship:    Date Of Birth:    Male   Female

3) First Name:              MI:            Last Name:     

    Relationship:    Date Of Birth:    Male   Female

4) First Name:              MI:            Last Name:     

    Relationship:    Date Of Birth:    Male   Female

5) First Name:              MI:            Last Name:     

    Relationship:    Date Of Birth:    Male   Female

 

 

 

Congratulations!  You have now completed your enrollment for insurance.  Please click on  the SUBMIT button below to submit your application for processing.   You will be contacted by a professional insurance agent/Enroller and/or Human Resource Department within the next 3 days and given a paper application on which to obtain your signature as well as any additional information needed to complete the application.  If you are not contacted within the specified period, please contact our customer services department immediately at (954)430-8475 or by e-mail at customer_service@workingamericanbenefits.com.

 

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Revised: 06/23/09