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ENROLL or WAIVE Coverage
Enter Enrollment Information on our Secure Site
*Required fields
First Name
Last Name
Gender
*
Required
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
*
Required
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
*
Required
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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