Employee 1 *

First Name

Last Name

Earnings Frequency

Per Hour

Per Year

Employee Status *

Single

Family

Sex *

Female

Male

Coverage Selection *

Single

Family

Waive Extended Health/Dental (Partner has benefited through their employer)

Occupation Classes (If applicable) *

Class A (Owner and Executive)

Class B (Management and Supervisors)

Class C (Front Line)

Date of Birth

MM

DD

YYYY

Date of Hire

MM

DD

YYYY

Employee 2

First Name

Last Name

Earnings Frequency

Hourly

Annually

Employee Status

Single

Family

Sex

Female

Male

Coverage Selection

Single

Family

Waive Extended Health/Dental (Partner has benefited through their employer)

Occupation Classes (If applicable)

Class A (Owner and Executive)

Class B (Management and Supervisors)

Class C (Front Line)

Date of Birth

MM

DD

YYYY

Date of Hire

MM

DD

YYYY

Employee 3

First Name

Last Name

Earnings Frequency

Option One

Option Two

Employee Status

Single

Family

Sex

Female

Male

Coverage Selection

Single

Family

Waive Extended Health/Dental (Partner has benefited through their employer)

Occupation Classes (If applicable)

Class A (Owner and Executive)

Class B (Management and Supervisors)

Class C (Front Line)

Date Birth

MM

DD

YYYY

Date of Hire

MM

DD

YYYY

Employee 4

First Name

Last Name

Earnings Frequency

Hourly

Annually

Employee Status

Single

Family

Sex

Female

Male

Coverage Selection

Single

Family

Waive Extended Health/Dental (Partner has benefited through their employer)

Occupation Classes (If applicable)

Class A (Owner and Executive)

Class B (Management and Supervisors)

Class C (Front Line)

Date of Birth

MM

DD

YYYY

Date of Hire

MM

DD

YYYY

Employee 5

First Name

Last Name

Earnings Frequency

Hourly

Annually

Employee Status

Single

Family

Sex

Female

Male

Coverage Selection

Single

Family

Waive Extended Health/Dental (Partner has benefited through their employer)

Occupation Classes (If applicable)

Class A (Owner and Executive)

Class B (Management and Supervisors)

Class C (Front Line)

Date of Birth

MM

DD

YYYY

Date of Hire

MM

DD

YYYY

Employee 6

First Name

Last Name

Earnings Frequency

Hourly

Annually

Employee Status

Single

Family

Sex

Female

Male

Coverage Selection

Single

Family

Waive Extended Health/Dental (Partner has benefited through their employer)

Occupation Classes (If applicable)

Single

Couple

Family

Waive Extended Health/Dental (Partner has benefited through their employer)

Date of Birth

MM

DD

YYYY

Date of Hire

MM

DD

YYYY

Employee 7

First Name

Last Name

Sex

Female

Male

Status

Single

Family

Coverage Selection

Single

Family

Waive Extended Health/Dental (Partner has benefited through their employer)

Occupation Class

Class A (Owner and Executive)

Class B (Management and Supervisors)

Class C (Front Line)

Date of Birth

MM

DD

YYYY

Date of Hire

MM

DD

YYYY

Employee 8

First Name

Last Name

Radio 34

Single

Family

Sex

Female

Male

Coverage Selection

Single

Family

Waive Extended Health/Dental (Partner has benefited through their employer)\

Occupation Classes

Class A (Owner and Executive)

Class B (Management and Supervisors)

Class C (Front Line)

Date of Birth

MM

DD

YYYY

Date of Hire

MM

DD

YYYY

Employee 9

First Name

Last Name

Earnings Frequency

Hourly

Annually

Status

Single

Family

Sex

Female

Male

Coverage Selection

Single

Family

Waive Extended Health/Dental (Partner has benefited through their employer)

Occupation Classes

Class A (Owner and Executive)

Class B (Management and Supervisors)

Class C (Front Line)

Date of Birth

MM

DD

YYYY

Date of Hire

MM

DD

YYYY

Employee 10

First Name

Last Name

Sex

Female

Male

Coverage Selection

Single

Family

Waive Extended Health/Dental (Partner has benefited through their employer)

Occupation Classes

Class A (Owner and Executive)

Class B (Management and Supervisors)

Class C (Front Line)

Date of Birth

MM

DD

YYYY

Date of Hire

MM

DD

YYYY