Production worker

Employee Benefits

CONFIRM YOUR SOCIAL SECURITY NUMBER (NO DASHES) *

State:

SC

ZIP CODE

29020

GENDER

F

DATE OF BIRTH

*/**/****

TELEPHONE NUMBER

803-***-****

GROUP

2914000

ARE YOU COVERED BY MEDICARE?

EMPLOYEE MEDICARE HIC#:

EMAIL ADDRESS

If you enter your email address, you will receive an email with your confirmation number and a copy of the Benefit Guide. Your employer may be copied on this notification.

LIMITED BENEFIT ENROLLMENT STATUS

Decline All Benefits

MEC ENROLLMENT STATUS

DECLINE MEC

247339238

* I certify that I read the benefit packet and understand its limitations. I understand that open enrollment is only available for a limited time. This serves as my electronic signature for the above election. Your confirmation number is : 2236122004293408

For questions or assistance, call Essential StaffCARE customer service at 1-866-***-****. To print a copy of this Enrollment Form, please click the "Print" button. PRINT ENROLLMENT FORM

Contact this candidate