Enrollment Employee Application for Group Health Insurance

For your security, our online applications are designed to automatically "time out" or end your session after 30 minutes of inactivity.

Once a page opens in your browser, you have 30 minutes to complete that page and continue to the next. Otherwise, your session will end and you will lose the information on that page.

For this reason, it is important to have the following information ready before you begin (especially if you have numerous medical conditions and/or dependents):

Medical History:

• Treatment dates
• Names of doctors/facilities
• Medication details

Required Software:

Adobe Acrobat Reader will allow you to view your completed application. If you don't already have this software, you can download it from the Adobe website.