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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
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