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Paper Craft

ENROLL or WAIVE Coverage

NOTE: If you are an HOURLY EMPLOYEE and wish to enroll in a medical plan,

you may only elect the UHC Base $6,750 Plan or the EBA MEC Plan.

Enter Enrollment Information on our Secure Site
*Required fields

First Name

Last Name

Social Security #

Date of Birth

Gender

Male

Female

Email

Date of Hire

Street Address

City

Region/State/Province

Postal / Zip code

CHOOSE PLAN(s)

Medical Plan Options

UHC PPO $2000

UHC HSA $2500

UHC Base $6750**

EBA MEC Plan**

Waive Medical Coverage

(choose only one)

Your Medical Plan Status

Employee Only

Employee + Spouse

Employee + Child(Children)

Family

Waive Ancillary Coverage

** Hourly employees may only elect UHC Base 6750 or EBA MEC Plan.

Ancillary Plan Options

Principal Dental - Employee Only

Principal Vision - Employee Only

Principal Life (Employer Paid)

Waive Ancillary Coverage

Dental - Add Dependent Status

EE + Spouse

EE + Child(ren)

EE + Family

Vision - Add Dependent Status

EE + Spouse

EE + Child(ren)

EE + Family

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

If you wish to cover additional dependents, please contact Amanda Garcia at (210) 283-5571.

Who are you employed by? *

MAD

CFR

RJC

What type of employee are you? *

Salary

Hourly

Your Signature

Thanks for submitting!

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