ENROLLMENT FORM

ENROLLMENT SUMMARY

For review purposes only. No additional changes can be submitted.


Thank you for completing the Staffmark Benefits portion of your hiring paperwork. Click the button below to close this window and enter the code word.

"health"


You must enter this code in order to move on to the next page of your hiring paperwork so please write this code down so you have it when you close this window. You can also use the copy/paste feature to enter the code on the Staffmark Employment Center Benefits page. To do so, use your mouse to highlight the code on this screen, once it is highlighted press Ctrl and C buttons on your keyboard at the same time. Then go to the Code field on the Benefits page of the Staffmark Employment Center and click your mouse into the field and then press Ctrl and V buttons on your keyboard at the same time.

This is a summary of your benefit elections including your confirmation number. Final determination of benefits, exact terms and exclusions of coverage for each plan will be provided in your certificate of coverage. Coverage will become effective the Monday following your first payroll deduction of premiums.


The Benefit Guide provides rates and a summary of the benefit choices available to you.
It is very important that you click and view this information prior to completing the enrollment form.
THE FIXED INDEMNITY MEDICAL PLAN IS A SUPPLEMENT TO HEALTH INSURANCE. IT IS NOT A SUBSTITUTE FOR ESSENTIAL HEALTH BENEFITS OR MINIMUM ESSENTIAL COVERAGE AS DEFINED UNDER THE AFFORDABLE CARE ACT (ACA).

The fixed indemnity medical, prescription drug, accidental loss of life, limb & sight, dental and vision plans are underwritten by BCS Insurance Company, Oakbrook Terrace, Illinois. The term life and short-term disability plans are underwritten by 4 Ever Life Insurance Company, Oakbrook Terrace, Illinois. Refer to the attached Benefit Guide for the accidental loss of life, limb & sight benefit information.
EMPLOYEE INFORMATION
(*  This denotes a required field)
TODAY'S DATE  (MM/DD/YYYY)
                 
 (NO DASHES) *
*

*
 
*
 
ADDRESS2
*
*
*
 
*
 (MM/DD/YYYY)*
Benefit coverage is only available to employees who are over the age of 18.
TELEPHONE NUMBER  (NO DASHES)
 
GROUP
ARE YOU COVERED BY MEDICARE?
 
EMAIL ADDRESS
 
If you enter your email address, you will receive a confirmation email that will include your name, last 4 digits of your SSN, benefits you elect or decline and the coverage level, if applicable. The confirmation email will also include a copy of the Benefit Guide and SBC, if applicable, for future reference.

The confirmation email will be sent from enrollment@verisource.com email address, and you will need to log into the site to view the email content.

Your employer may be copied on this notification. 		 
*
 
CHOOSE FROM THE BENEFIT OPTIONS BELOW
*
Please note that your coverage level selected will apply to all limited benefits products.
 
*
 
*
 
*
 
*
*
DEPENDENT INFORMATION (SPOUSE OR CHILDREN)
DEPENDENT
RELATIONSHIP
DEPENDENT
FIRST NAME
DEPENDENT
LAST NAME
DEPENDENT
MEDICARE HIC#
DEPENDENT
GENDER
DEPENDENT
DOB  (MM/DD/YYYY)
DEPENDENT
SOCIAL SECURITY
BENEFICIARY INFORMATION
For Accidental Loss of Life, Limb & Sight, Term Life or Accidental Death and Dismemberment, please enter your beneficiary information.
BENEFICIARY NAME RELATIONSHIP BENEFICIARY SOCIAL SECURITY #  
 
 
 
 
 
 (NO DASHES)*
Your confirmation number is 000000000. .

For questions or assistance, call EssentialCare customer service at 1-866-798-0803.

To print a copy of this Enrollment Form, please click the "Print" button.

In order to submit your eForm, you must complete the certification statement and check off the certification box.