Small Business Health Benefits Enrollment Form
First Name
Last Name
Date of Birth
SSN (Last 4 Digits)
Home Address
City
State
ZIP Code
Phone Number
Email Address
Coverage Type
Employee Only
Employee + Spouse
Employee + Child(ren)
Family
Plan Selection
Select Plan
Basic
Standard
Premium
Dependent Information (if applicable)
Dependent 1 Name
Date of Birth
Relationship
Dependent 2 Name
Date of Birth
Relationship
Additional Notes