GROUP NAME:
GROUP EMAIL:
GROUP ADDRESS:
City: State / Territory Alabama (AL)Alaska (AK)Arizona (AZ)Arkansas (AR)California (CA)Colorado (CO)Connecticut (CT)Delaware (DE)Florida (FL)Georgia (GA)Hawaii (HI)Idaho (ID)Illinois (IL)Indiana (IN)Iowa (IA)Kansas (KS)Kentucky(KY)Louisiana (LA)Maine (ME)Maryland (MD)Massachusetts (MA)Michigan (MI)Minnesota (MN)Mississippi (MS)Missouri (MO)Montana (MT)Nebraska (NE)Nevada (NV)New Hampshire (NH)New Jersey (NJ)New Mexico (NM)New York (NY)North Carolina (NC)North Dakota (ND)Ohio (OH)Oklahoma (OK)Oregon (OR)Pennsylvania (PA)Rhode Island (RI)South Carolina (SC)South Dakota (SD)Tennessee (TN)Texas (TX)Utah (UT)Vermont (VT)Virginia (VA)Washington (WA)West Virginia (WV)Wisconsin (WI)Wyoming (WY)American Samoa (AS)District of Columbia (DC)Federated States of Micronesia (FM)Guam (GU)Marshall Islands (MH)Northern Mariana Islands (MP)Palau (PW)Puerto Rico (PR)Virgin Islands (VI)Armed Forces Africa (AE)Armed Forces Americas (AA)Armed Forces Canada (AE)Armed Forces Europe (AE)Armed Forces Middle East (AE)Armed Forces Pacific (AP) Zip Code:
EFFECTIVE DATE:
INDUSTRY:
REQUESTING AGENCY: Benefits Alliance, LLC
NAME/INITIALS
GENDER
EMPLOYEE DOB/AGE
SPOUSE DOB/AGE
CHILD 1 AGE/DOB
CHILD 2 AGE/DOB
CHILD 3 AGE/DOB
CHILD 4 AGE/DOB
TYPE OF COVERAGE
LOCATION STATE
MaleFemaleOther
—Please choose an option—EE = EMPLOYEE ONLYES = EMPLOYEE & SPOUSEEC = EMPLOYEE & CHILDFAM = FAMILYW = WAIVER
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