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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
CHOOSE PLAN(s)
Date of Hire
UHC Medical Plan Options:
UHC PPO $2000 (Salary team members only)
UHC HSA $2500 (Salary team members only)
UHC BASE $6750**
EBA MEC Plan**
Waive Medical Coverage
Medical Coverage Level
Employee Only
Employee + Spouse
Employee + Child(ren)
Family
I am waiving medical coverage
** Hourly employees may only elect UHC Base 6750 or EBA MEC Plan.
UHC Dental Plan Options
UHC Dental DPPO
UHC Dental DHMO
Waive Dental Coverage
Dental - Add Dependent Coverage
I don't want Dental Coverage
Employee Only
EE + Spouse
EE + Child(ren)
EE + Family
UHC Vision
UHC Vision
Waive Vision Coverage
Vision - Add Dependent Coverage
I don't want Vision coverage
Employee Only
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
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
Percentage to Beneficiary 4
Relationship 4
TOTAL = 100%
Voluntary Life Insurance $50,000 - $500,000 of Life/AD&D Benefit
Yes, I would like to receive information about additional Voluntary Life/AD&D.
No, I am not interested in additional life coverage.
If you wish to cover additional dependents or add more beneficiaries, please contact Amanda Garcia at (210) 283-5571.
Organization you work for:
MAD
CFR
RJC
ORI
What type of employee are you?
Salary
Hourly
Your Signature
Clear
Submit
Thanks for enrolling!
Please note that you will
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receive an email confirmation.
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