Welcome to United Agencies Inc.

NEWLY COVERED EMPLOYEE FORM

NAME OF EMPLOYER
Name of Person Submitting this Form
Email Address of Person Submitting Form
Employee First Name
Last Name
Home Address
City
State
Zip
Social Security #
Date of Birth
Date of Hire
Date Coverage Effective
Send Notice in	English Spanish
Name of Medical Plan Enrolled In? (HMO, PPO, etc.)
Type of Medical Coverage:	Employee Only EE & Spouse EE & Children Family WAIVED
Medical Coverage Premium:
Name of Dental Plan Enrolled In? (HMO, PPO, etc.)
Type of Dental Coverage:	Employee Only EE & Spouse EE & Children Family WAIVED
Dental Coverage Premium:
Name of any other plan enrolled in? (Vision, Chiropractic, etc.)
Type of Other Coverage:	Employee Only EE & Spouse EE & Children Family WAIVED
Other Plan Premium:
Flexible Spending Plan Contribution?:
Spouse Name (Full Name)
Full Names of any covered children
Alternative Address for Dependents