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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

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

Thanks for enrolling!

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ENROLL or WAIVE Coverage

Enter Enrollment Information on our Secure Site *Required fields

CHOOSE PLAN(s)

(choose only one dental plan OR waive dental coverage)

Add Dependent Information

UHC Life/AD&D Insurance Beneficiary Information

TOTAL = 100%

If you wish to cover additional dependents or add more beneficiaries, please contact Amanda Garcia at 210-283-5571.

Thanks for enrolling!

Enter Enrollment Information on our Secure Site
*Required fields