Benefit Elections

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First Name
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Last Name
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Social Security Number
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Address
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City
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State
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  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming
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Zipcode
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Date of Birth
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Email Address
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Phone Number
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Preferred Gender
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Company Name
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Type of Change
  • - select a option -
  • New Election
  • Change My Info
  • Terminate Coverage
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Health Insurance
  • - select a option -
  • PPO Silver Secure
  • HMO Gold Proactive
  • HMO Silver Proactive
  • Waive: I decline health insurance
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Dental Insurance
  • - select a option -
  • PPO Dental
  • Waive: I decline dental insurance
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Vision Insurance
  • - select a option -
  • Eyemed Vision
  • Waive: I decline vision insurance
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Disability Insurance
  • - select a option -
  • Colonial Disability
  • Waive: I decline disability insurance
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Accident Insurance
  • - select a option -
  • Colonial Accident
  • Waive: I decline disability insurance
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Cigarette Smoker?
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Your Physician
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Insurance Effective Date
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Dependents to Enroll
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Dependents to Enroll
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Spouse First Name
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Spouse Last Name
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Spouse Date of Birth
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Spouse SSN
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Spouse's Gender
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Cigarette Smoker?
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Health Insurance
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Dental Insurance
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Vision Insurance
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Disability Insurance
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Accident Insurance
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Spouse's Primary Physician
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Child 1 First Name
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Child 1 Last Name
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Child 1 Date of Birth
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Child 1 SSN
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Child 1 Gender
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Cigarette Smoker?
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Child 1 Health Insurance
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Child 1 Dental Insurance
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Child 1 Vision Insurance
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Child 1 Accident Insurance
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Child 1 Physician
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Child 2 First Name
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Child 2 Last Name
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Child 2 Date of Birth
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Child 2 SSN
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Child 2 Gender
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Child 2 Cigarette Smoker?
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Child 2 Health Insurance
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Child 2 Dental Insurance
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Child 2 Vision Insurance
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Child 2 Accident Insurance
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Child 2 Physician
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Child 3 First Name
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Child 3 Last Name
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Child 3 Date of Birth
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Child 3 SSN
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Child 3 Gender
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Child 3 Cigarette Smoker?
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Child 3 Health Insurance
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Child 3 Dental Insurance
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Child 3 Vision Insurance
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Child 3 Accident Insurance
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Child 3 Physician
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Child 4 First Name
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Child 4 Last Name
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Child 4 Date of Birth
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Child 4 SSN
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Child 4 Gender
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Child 4 Cigarette Smoker?
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Child 4 Health Insurance
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Child 4 Dental Insurance
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Child 4 Vision Insurance
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Child 4 Accident Insurance
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Child 4 Physician
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Child 5 First Name
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Child 5 Last Name
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Child 5 Date of Birth
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Child 5 SSN
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Child 5 Gender
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Child 5 Cigarette Smoker?
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Child 5 Health Insurance
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Child 5 Dental Insurance
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Child 5 Vision Insurance
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Child 5 Accident Insurance
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Child 5 Physician
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Signature
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