Benefits Enrollment Please enable JavaScript in your browser to complete this form. - Step 1 of 4Employer Name *Effective Date *Name *FirstLastDivision *Social Security Number *Date of Birth *Gender *Please Select...MaleFemaleMarital Status *Please Select...SingleMarriedDivorcedMailing Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone NumberOriginal Date of HireAnnual Salary *NextSpouseSpouse's Full NameFirstMiddleLastSpouse's Date of BirthSpouse's Social Security NumberDependent #1Full NameFirstMiddleLastGenderPlease Select...MaleFemaleDate of BirthSocial Security NumberRelationship (son/daughter/stepchild/etc.)Dependent #2Full NameFirstMiddleLastGenderPlease Select...MaleFemaleDate of BirthSocial Security NumberRelationship (son/daughter/stepchild/etc.)Dependent #3Full NameFirstMiddleLastGenderPlease Select...MaleFemaleDate of BirthSocial Security NumberRelationship (son/daughter/stepchild/etc.)NextMedicalCurrent Level of Medical CoveragePlease Select...Employee OnlyEmployee Plus SpouseEmployee Plus Child(ren)Employee Plus FamilyI Declined Medical CoveragePlease check if you have declined coverageReason for Declining Medical CoveragePlease Select...Other CoverageWaive CoverageNot Covered Under Other CoverageChange In Medical Coverage?Please Select...YesNoMedical Coverage ChangeCancel EmployeeCancel DependentIndicate Medical Coverage Event DateDentalCurrent Level of Dental CoveragePlease Select...Employee OnlyEmployee Plus 1 (Multiple Children elect Family Coverage)Employee Plus FamilyI Declined Dental CoveragePlease check if you have declined coverageReason for Declining Dental CoveragePlease Select...Other CoverageWaive CoverageNot Covered Under Other CoverageChange In Dental Coverage?Please Select...YesNoDental Coverage ChangeCancel EmployeeCancel DependentIndicate Dental Coverage Event DateVisionCurrent Level of Vision CoveragePlease Select...Employee OnlyEmployee Plus SpouseEmployee Plus Child(ren)Employee Plus FamilyI Declined Vision CoveragePlease check if you have declined coverageReason for Declining Vision CoveragePlease Select...Other CoverageWaive CoverageNot Covered Under Other CoverageChange In Vision Coverage?Please Select...YesNoVision Coverage ChangeCancel EmployeeCancel DependentIndicate Vision Coverage Event DateNextPrimary BeneficiaryAll Primary Beneficiaries must equal 100%1. Name *FirstLast1. AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code1. Social Security Number1. Percent Alloted1. Relationship2. Name *FirstLast2. AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code2. Social Security Number2. Percent Allotted2. RelationshipContingent BeneficiaryName *FirstLastAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSocial Security NumberPercent AllottedRelationshipNameSubmit23415 COMPANY About Us Careers NAVIGATION Services Resources Client Info Employee Info Contact Us CONTACT Office: 469-470-1077 Fax: 214-975-2331 4100 Spring Valley Road Suite 654 Dallas, TX 75035
