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ENROLL - Employee Portal

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Paper Craft

ENROLL or WAIVE Coverage

SPRING VALLEY JACK

Enter Enrollment Information on our Secure Site
*Required fields

First Name

Last Name

Social Security #

Date of Birth

Gender

Male

Female

Phone

Email

Date of Hire

Street Address

City

Region/State/Province

Postal / Zip code

CHOOSE BENEFITS:

Medical Plan Options

EBA MEC Plan**

Waive Medical Coverage

(choose only one)

Your Medical Plan Status

Employee Only

Employee + Spouse

Employee + Child(Children)

Family

I Waive Medical Coverage

Ancillary Plan Options

Principal Dental - I want Dental

Principal Vision - I want Vision

Waive Both Dental and Vision

Dental - Add Dependent Status

I don't want Dental benefits.

EE Only

EE + Spouse

EE + Child(ren)

EE + Family

Vision - Add Dependent Status

I don't want Vision benefits.

EE 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

Dependent 5

Spouse

Child

Dependent 5 Date of Birth

Dependent 5 SS#

Male

Female

Who are you employed by?

Jack in the Box

Edible Arrangements

Your Signature

Thank you for submitting!NOTE:  You will NOT receive an email confirmation.

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