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ENROLL or WAIVE Coverage
Enter Enrollment Information on our Secure Site
*Required fields
First Name
Last Name
Gender
Male
Female
Email
Social Security #
Date of Birth
Phone
Street Address
City
Region/State/Province
Postal / Zip code
Date of Hire
CHOOSE PLAN(s)
UHC Dental Plan Options
UHC Dental DPPO
UHC Dental DHMO
Waive Dental Coverage
Dental - Coverage Level
Employee Only
EE + Spouse
EE + Child(ren)
EE + Family
Waive Dental
(choose only one dental plan OR waive dental coverage)
UHC Vision
UHC Vision
Waive Vision Coverage
Vision - Coverage Level
Employee Only
EE + Spouse
EE + Child(ren)
EE + Family
Waive Vision
Add Dependent Information
Dependent 1
Spouse
Child
Dependent 1 Date of Birth
Dependent 1 SS#
Male
Female
Dependent 2
Spouse
Child
Dependent 2 Date of Birth
Dependent 2 SS#
Male
Female
Dependent 3
Spouse
Child
Dependent 3 Date of Birth
Dependent 3 SS#
Male
Female
Dependent 4
Spouse
Child
Dependent 4 Date of Birth
Dependent 4 SS#
Male
Female
UHC Life/AD&D Insurance Beneficiary Information
Employer paid flat $15,000 Life/AD&D benefit.
Life Beneficiary 1
Beneficiary 1 Social Security
Percentage to Beneficiary 1
Relationship 1
Life Beneficiary 2
Beneficiary 2 Social Security
Percentage to Beneficiary 2
Relationship 2
Life Beneficiary 3
Beneficiary 3 Social Security
Percentage to Beneficiary 3
Relationship 3
Life Beneficiary 4
Beneficiary 4 Social Security
Supplemental Life/AD&D
Yes, I would like to receive information about additional Voluntary Life/AD&D.
No, I am not interested in additional life coverage.
Percentage to Beneficiary 4
Relationship 4
TOTAL = 100%
If you wish to cover additional dependents or add more beneficiaries, please contact Amanda Garcia at 210-283-5571.
Organization you work for:
Yadav Enterprises
Pala Mesa
Sizzler
The Bridges
Denny's (CA)
Jack in the Box
Corner Bakery
Eagle Ridge
Greenhorrn Creek
What type of employee are you?
Salary
Hourly
Your Signature
Clear
Submit
Thanks for enrolling!
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