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ENROLL or WAIVE Coverage

Enter Enrollment Information on our Secure Site
*Required fields

First Name

Last Name

Gender

Male

Female

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

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

Thanks for enrolling!
Please note that you will not receive an email confirmation.

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ENROLL or WAIVE Coverage

Enter Enrollment Information on our Secure Site *Required fields

CHOOSE PLAN(s)

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

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! Please note that you will not receive an email confirmation.

Enter Enrollment Information on our Secure Site
*Required fields

Thanks for enrolling!
Please note that you will not receive an email confirmation.