Healthcare-Only Benefits Enrollment Form
First Name
Last Name
Date of Birth
SSN/Member ID
Address
City
State
ZIP Code
Contact Information
Phone Number
Email Address
Coverage Election
Select Healthcare Plan
Basic
Plus
Premium
Coverage Type
Employee Only
Employee + Spouse
Employee + Children
Family
Dependents (if applicable)
Dependent Name
DOB
Relationship
Additional Information
Special Notes or Comments
Enrollment Authorization
Signature
Date