2. My ZIP Code:
At Home:
At Work:

3. I am:
Single
Married
Married with children

4. I am interested in participating in one of the following medical insurance plans, if offered:
Employee Single ($57.78 per week)
Employee with spouse ($126.53 per week)
Employee with one child ($92.55 per week)
Employee with children ($92.55 per week)
Employee with family ($170.95 per week)
No thanks, I have medical coverage elsewhere.
No thanks, I don't want medical coverage.

5. I am interested in participating in one or more of the following employee benefit coverages, if offered:
Dental plan ($6.22 per week)
Vision plan ($1.80 per week)
Life insurance ($1.25 per week for $25,000 coverage)
Short Term Disability
Long Term Disability

6. I am interested in my dependents participating in one or more of the following employee benefit coverages, if offered:
Dental plan
Vision plan
Dependent Life ($1.75 per month)

7. My work email address is: