SAMPLE VIP ENROLLMENT WEEKLY 2025

SAMPLE ----- Your enrollment has never been easier!

This is your simplified beginning-to-end enrollment form so you are able to protect your income and provide financial security. ALL employees/members are asked to complete this form regardless of acceptance of benefits. Please fill out all fields completely and accurately. Rates are WEEKLY unless indicated otherwise.
Discover the importance of protecting your financial future with just 1 minute and 23 seconds of your time.
Part 1. - Required information

Hi there! Please complete the following fields. This is needed in order to give you your correct benefits eligibility and rates.
ATTENTION!

ALL INFORMATION BELOW MUST BE COMPLETE TO CALCULATE YOUR CORRECT BENEFITS ELIGIBILITY AND PREMIUMS.
Your Name*

First NameLast Name
Your email address (for your policy delivery and wellness benefits)*
You will NEVER receive spam from us.
Gross ANNUAL Income*
This is what you earn in an ENTIRE YEAR, BEFORE TAXES are taken out. Enter the TOTAL amount of YOUR income.
Date of Birth*

MonthDayYear
ATTENTION!

ALL INFORMATION ABOVE MUST BE COMPLETE TO CALCULATE YOUR CORRECT BENEFITS ELIGIBILITY AND PREMIUMS.
Date (HIDE)

MonthDayYear
Date
Current Age (HIDE)
This is a calculated field. You do not need to enter anything.
Age Range (HIDE ON FINAL)
Show Assurity Short Term Disability (HIDE)

YesNo
Show Assurity Group Life Products (HIDE)

Yes, group size 10-99Yes, group size over 100No

Part 2. - Your offerings, policy details, rates, and election options.

If you are employed... these benefits are important! We come to work to earn a living. Let's protect what matters most.
Group Term Life Insurance

Assurity Group Term Life Insurance offers employees the choice of a 10-year or 20-year term policy, up to $100,000 or $150,000 extendable to their spouse and children. This special Guaranteed Issue opportunity allows securing coverage without answering health questions, ensuring financial security for loved ones.
Need more information on this plan and how it works for you and your family? Simply check this box!

Show me the 1 minute video and plan details
Assurity Group Term Life Insurance

Are you looking to secure the financial future of your loved ones? Look no further than Assurity Group Term Life Insurance. As an employee, you have the opportunity to choose either a 10-year or 20-year term policy with coverage up to $100,000. What's more, you can extend this coverage to your spouse for up to $30,000 and your children for up to $10,000.

Special Features:
Guaranteed Issue: At this enrollment, you can take advantage of a special Guaranteed Issue opportunity. This means you can secure coverage up to the specified amounts without having to answer any health questions, making it an extremely rare opportunity.

Key Benefits:
No Health Questions: Enjoy the peace of mind that comes with securing coverage for yourself, your spouse, and your children without the hassle of health questions.
Financial Security: Ensure that your loved ones are financially secure in the event of an unforeseen circumstance.

Act Now!
Don't miss out on this exceptional opportunity to provide financial protection for your family.

Special Note for employees over age 60:
You are eligible for 10 year term policies and a maximum of $50,000 in coverage. You can still extend your coverage to add your spouse or dependent children.
Group Term Life Lookup
What length of coverage would you like?*

10 Years20 Years
What amount of coverage would you like to enroll in?*

$25,000$50,000$75,000$100,000
What amount of coverage would you like to enroll in?*

$25,000$50,000$75,000$100,000$150,000
Who do you want to cover with Assurity Group Term Life Coverage? Spouses receive 30% of the benefit amount and children receive 10% of the benefit amount.*

Employee OnlyEmployee + SpouseEmployee + Child(ren)Employee + Spouse + Child(ren)No thanks, I don't want any life insurance coverage
Assurity Life Age Range (ALWAYS HIDDEN)
Group Term Life Calculation (ALWAYS HIDDEN!)
Your paycycle premium is:
This is the amount you pay per paycheck to have amazing life insurance benefits!
Beneficiary Name*

First NameLast Name
Relationship to Beneficiary*
Beneficiary Date of Birth*

MonthDayYear
Date
Group Hospital Indemnity Insurance plus Observation with Critical Illness & Cancer

Pays a $2,500 Lump Sum cash benefit for any hospital admission or hospital observation. Pays a $10,000 benefit for a Critical Illness or Cancer diagnosis. Simple, Affordable, Necessary.
Need more information on this plan and how it works for you and your family? Simply check this box!

Show me the 1 minute video and plan details
- No deductibles, copays, coinsurance or networks (see any doctor)
- Guaranteed issue – no medical exams or tests
- Portable – coverage continues if you retire or change jobs, as long as you pay the premiums
Hospital indemnity insurance provides crucial financial protection by offering additional cash benefits to cover expenses related to a hospital stay. It ensures peace of mind, helping you pay for medical costs, deductibles, and other expenses not covered by your primary health insurance.

Enjoy the benefit of receiving the same pricing as an 18-year-old, regardless of your age!

Coverage Includes:
- $2,500 Hospital Admission Benefit - Minimum of 20 hours admission.
- $2,500 Hospital Observation - Minimum of 20 hours observation as outpatient. Observation Care for 20-48 and for 49 hours or more.
- Mental, nervous disorder, and substance abuse inpatient services benefits.
- $10,000 in Critical Illness and Invasive Cancer Benefit
___________________________
Group Hospital Indemnity Insurance - $2,500 Hospital Admission, $2,500 Hospital Observation, + $10,000 in CI Cancer benefits - Don't start off in a hole!*

Employee Only / $8.68Employee + Spouse / $17.70Employee + Dependents / $14.39Employee + Spouse + Dependents / $23.42No thanks, I am waiving this benefit
Group Accident Expense Insurance

Accident indemnity insurance is essential for providing financial protection in case of unexpected accidents. It offers additional cash benefits to help cover medical expenses, transportation costs, and other out-of-pocket expenses that may arise due to an accident
Need more information on this plan and how it works for you and your family? Simply check this box!

Show me the 1 minute video and plan details
- Helps with out-of-pocket expenses associated with covered accidents
- No deductibles, copays, coinsurance or networks - see any doctor
- Guaranteed issue – no medical exams or tests
- Portable – coverage continues if you retire or change jobs, as long as you pay the premiums
  
  Accident indemnity insurance is essential for providing financial protection in case of unexpected accidents. It offers additional cash benefits to help cover medical expenses, transportation costs, and other out-of-pocket expenses that may arise due to an accident.
________________________
Off-the-job ACCIDENT Coverage - Choose now.*

Employee Only / $4.04Employee + Spouse / $7.00Employee + Dependents / $8.43Employee + Spouse + Dependents / $12.43No thanks, I am waiving this benefit
24 Hour ACCIDENT Coverage - Choose now.*

Employee Only / $4.67Employee + Spouse / $8.11Employee + Dependents / $9.21Employee + Spouse + Dependents / $13.71No thanks, I am waiving this benefit
Group Short Term Disability Insurance

Short-Term Disability Income insurance pays a weekly benefit directly to you if you are sick or injured and can’t work.
Need more information on this plan and how it works for you and your family? Simply check this box!

Show me the 1 minute video and plan details
- Disability insurance is crucial as it provides income protection if you become unable to work due to an injury or illness. It ensures financial stability by replacing a portion of your lost income, allowing you to meet your essential expenses and maintain your lifestyle during a period of disability.
  
  BOTTOM LINE: Group Short-Term Disability Income insurance pays a weekly benefit directly to you if you are sick or injured and can’t work.
  _______________________
You qualify for THIS MUCH in WEEKLY disability benefits: (HIDE THIS)
This number is how much you will receive in dollars weekly disability benefits TAX FREE. This is a calculated field. You do not need to enter anything here.
Your benefits would pay continuously for the following weeks per accident/illness:*

13 Weeks26 Weeks
Waiting period to receive benefits after an illness is (0 days waiting for injury):*

7 Days14 Days
Short Term Variables Calculation (HIDE THIS)
Casebuilder Lookup Spreadsheet
You must earn over $21,750/year to receive disability benefits. If you need to make a correction on your annual income, simply hit the back button at the bottom of this page.
You qualify for $250 in Weekly Tax-Free Disability Benefits - Your Cost/PayCycle is:
Paycycle Premium
You qualify for $300 in Weekly Tax-Free Disability Benefits - Your Cost/PayCycle is:
Paycycle Premium
You qualify for $350 in Weekly Tax-Free Disability Benefits - Your Cost/PayCycle is:
Paycycle Premium
You qualify for $400 in Weekly Tax-Free Disability Benefits - Your Cost/PayCycle is:
Paycycle Premium
You qualify for $450 in Weekly Tax-Free Disability Benefits - Your Cost/PayCycle is:
The amount in the box is the pay-cycle premium for $450 per week in benefits paid to you.
You qualify for $500 in Weekly Tax-Free Disability Benefits - Your Cost/PayCycle is:
Paycycle Premium
You qualify for $550 in Weekly Tax-Free Disability Benefits - Your Cost/PayCycle is:
Paycycle Premium
You qualify for $600 in Weekly Tax-Free Disability Benefits - Your Cost/PayCycle is:
Paycycle Premium
You qualify for $650 in Weekly Tax-Free Disability Benefits - Your Cost/PayCycle is:
Paycycle Premium
You qualify for $700 in Weekly Tax-Free Disability Benefits - Your Cost/PayCycle is:
Paycycle Premium
You qualify for $750 in Weekly Tax-Free Disability Benefits - Your Cost/PayCycle is:
Paycycle Premium
You qualify for $800 in Weekly Tax-Free Disability Benefits - Your Cost/PayCycle is:
Paycycle Premium
You qualify for $850 in Weekly Tax-Free Disability Benefits - Your Cost/PayCycle is:
Paycycle Premium
You qualify for $900 in Weekly Tax-Free Disability Benefits - Your Cost/PayCycle is:
Paycycle Premium
You qualify for $950 in Weekly Tax-Free Disability Benefits - Your Cost/PayCycle is:
Paycycle Premium
You qualify for $1000 in Weekly Tax-Free Disability Benefits - Your Cost/PayCycle is:
Paycycle Premium
Your disability rate and eligibility is calculated by using the information you provided on the previous page.

NOTE: If you do not see your weekly disability benefit amount and rate above, please refresh this page.

We apologize for the minor technical issue if this occurs.
Decision time! Let's Protect that paycheck you work so hard for.*

Yes, I want to protect my income with disability benefits.No thanks, I waive this coverage.
Paycycle Cost For Short Term Disability: (HIDE)
Lump Sum Critical and Cancer Illness Insurance

Group Critical Illness insurance pays a lump-sum benefit directly to you if you are diagnosed with cancer, stroke, heart attack or a number of other covered conditions.
Need more information on this plan and how it works for you and your family? Simply check this box!

Show me the 1 minute video and plan details

Who do you want to protect? Children are automatically included for FREE when you cover yourself! (A selection is required to calculate your rates)*

Employee Only / Employee + ChildrenEmployee + Spouse / Employee + Spouse + Children
Assurity Critical Illness Age Range
Assurity Critical Illness Variable Calculation
Assurity Variables Input
Be sure to choose an option above to see your calculated rates below.
$10,000 Lump Sum Benefit Amount Cost
The amount in the box is the pay cycle premium to receive a $10,000 lump sum payout for you and your family.
$20,000 Lump Sum Benefit Amount Cost
The amount in the box is the pay cycle premium to receive a $20,000 lump sum payout for you and your family.
$30,000 Lump Sum Benefit Amount Cost
The amount in the box is the pay cycle premium to receive a $30,000 lump sum payout for you and your family.
How much Assurity Critical Illness/Cancer coverage do you want to enroll in?*

$10,000 Lump Sum Benefit$20,000 Lump Sum Benefit$30,000 Lump Sum BenefitNo thanks, I don't want to enroll in critical illness coverage
Assurity CI Monthly investment based on my benefit selection above: (HIDE)
"3/6/9" GROUP WHOLE LIFE INSURANCE

Whole Life Insurance that has LIVING benefits in case of a chronic illness or permanent injuries.
Need more information on this plan and how it works for you and your family? Simply check this box!

Show me the 1 minute video and plan details
HOW IT WORKS:
- AT TIME OF DEATH - Beneficiary is paid the Death benefit chosen
- CASH VALUE - Policy builds Cash Value over time allowing you to borrow against it if needed.
- WHOLE LIFE - This is permanent insurance for the rest of your life with no rate increases.
- LIVING BENEFIT RIDER FOR CHRONIC CARE - If the insured cannot perform 2 or more Activities of Daily Living, you can advance the benefit amount minus $5,000 to take care of your needs. No licensed medical care required. It can even be friends or family caring for you.
- LIVING BENEFIT RIDER FOR TERMINAL ILLNESS - If a condition resulting in an expected life span of 12 months or less (certified by a physician) occurs, you can advance 75% of your death benefit.
YOU CHOOSE HOW MUCH YOU WISH TO INVEST IN LIFE INSURANCE! Choose either $3, $6, or $9 per week in premiums. This will determine how much coverage you can have based upon your age.

TAKE ADVANTAGE with NO HEALTH QUESTIONS!

BROCHURE CAN BE DOWNLOADED HERE

________________________
Based on your age, the benefit amount is shown below for each amount you can invest per week in life insurance. Some options may be marked n/a due to being outside of the allowable issue limits.
Age and Rate Finder
$3.00 Per Week - Benefit amount:
This is the face value of your life insurance policy.
$6.00 Per Week - Benefit amount:
This is the face value of your life insurance policy.
$9.00 Per Week - Benefit amount:
This is the face value of your life insurance policy.
I would like to invest*

$3.00 Per Week$6.00 Per Week$9.00 Per WeekNo thanks, I want to waive life insurance coverage
100% Beneficiary's Legal Name*

First NameLast Name
Beneficiary's Date of Birth*

MonthDayYear
Beneficiary's Relationship To You*
5Star Life Group Accident Insurance

Accident indemnity insurance is essential for providing financial protection in case of unexpected accidents. It offers additional cash benefits to help cover medical expenses, transportation costs, and other out-of-pocket expenses that may arise due to an accident
Need more information on this plan and how it works for you and your family? Simply check this box!

Show me the 1 minute video and plan details
- Helps with out-of-pocket expenses associated with covered accidents
- No deductibles, copays, coinsurance or networks - see any doctor
- Guaranteed issue – no medical exams or tests
- Portable – coverage continues if you retire or change jobs, as long as you pay the premiums
  
  Accident indemnity insurance is essential for providing financial protection in case of unexpected accidents. It offers additional cash benefits to help cover medical expenses, transportation costs, and other out-of-pocket expenses that may arise due to an accident.
________________________
5Star Life ACCIDENT Coverage - Choose now.*

Employee Only / $4.30Employee + Spouse / $6.61Employee + Dependents / $8.49Employee + Spouse + Dependents / $12.96No thanks, I am waiving this benefit
5Star Life Group Hospital Indemnity Insurance

Pays a Lump Sum cash benefit for any hospital admission. Pays daily confinement benefits. Pays daily benefits for Outpatient Substance abuse care and mental/nervous disorder facilities. Simple, Affordable, Necessary.
Need more information on this plan and how it works for you and your family? Simply check this box!

Show me the 1 minute video and plan details
- No deductibles, copays, coinsurance or networks (see any doctor)
- Guaranteed issue – no medical exams or tests
- Portable – coverage continues if you retire or change jobs, as long as you pay the premiums
Hospital indemnity insurance provides crucial financial protection by offering additional cash benefits to cover expenses related to a hospital stay. It ensures peace of mind, helping you pay for medical costs, deductibles, and other expenses not covered by your primary health insurance.

Enjoy the benefit of receiving the same pricing as an 18-year-old, regardless of your age!

___________________________
5Star Life - Hospital Indemnity Insurance - Choose One*

Employee Only / $6.53Employee + Spouse / $14.28Employee + Dependents / $8.25Employee + Spouse + Dependents / $16.32No thanks, I am waiving this benefit
5STAR LIFE INSURANCE

Choose $25,000, $50,000 or $100,000 in Term to Age 121 Life Insurance with Living Benefits!
Need more information on this plan and how it works for you and your family? Simply check this box!

Show me the 1 minute video and plan details
5Star Age Look Up
$25,000 Benefit / Cost Per Paycycle
$50,000 Benefit / Cost Per Paycycle
$100,000 Benefit / Cost Per Paycycle
Which amount of coverage would you like to enroll in?*

$25,000 Benefit$50,000 Benefit$100,000 BenefitNo thanks, I'm waiving 5Star Life Insurance
5Star paycyle employee cost pass through (HIDE)
Primary Beneficiary Name*
Beneficiary Relationship*

SpouseChildOther
Would you like to cover a spouse with $15,000 worth of coverage?*

YesNo
Please select your spouse's age to get a premium cost per paycycle*
5Star Spouse Age Lookup
$15,000 Spouse Coverage / Cost Per Paycycle
Spouse's Social Security Number*
5Star Life Insurance can also provide life insurance benefits for dependent children in the amount of $10,000 per child.

Full-time students can be covered until age 26; non-students can be covered until age 23.
Would you like to cover your dependents for a flat rate of $2 per month?*

YesNo
DENTAL/VISION INSURANCE

GREAT DENTAL INSURANCE! ! $2,000/Annual benefits - NO WAITING PERIODS!
Need more information on this plan and how it works for you and your family? Simply check this box!

Show me the 1 minute video and plan details
$2000/year in Dental Benefits with NO WAITING PERIODS.

HUGE PPO Network. Covers the entire family.

PLAN INCLUDES BEAM PERKS!

Every Beam member receives complimentary Beam Perks. The member welcome kit contains a sonic-powered, smart, electronic toothbrush, custom formulated toothpaste, dental floss, and access to the Beam App and Member Portal.

Delivered every 6 months, enrolled members in every plan receive a Beam Perks kit that includes replacement heads and batteries, toothpaste, and dental floss.

YOU MUST REGISTER TO RECEIVE YOUR TOOTHBRUSH & SUPPLIES WITHIN 45 DAYS OF YOUR PLAN EFFECTIVE DATE.

___________________________________
SMILE! - Choose some awesome BEAM Dental Insurance!*

Employee Only / $10.34Employee + Spouse / $20.67Employee + Children / $26.05Employee + Spouse + Children / $36.39No thanks, I want to waive dental insurance
LOOK HERE! - Choose great VSP Vision Insurance - SEE the difference!*

Employee Only / $2.20Employee + Spouse / $4.40Employee + Children / $3.84Employee + Spouse + Children / $6.04No thanks, I want to waive vision insurance
DOES YOUR FAMILY NEED A PRIMARY CARE PHYSICIAN?

Primary virtual medical care services, Prescriptions, Behavioral Health Care, Employee Assistance Programs, Conditions Management, At-home Labs, Genomic Testing, and MUCH more for your entire household at an extremely low price!
Need more information on this plan and how it works for you and your family? Simply check this box!

Show me the 4 minute video and plan details
$0 Copays for Virtual Primary Care, Virtual Urgent Care, At Home Labs, Many Prescriptions, On Demand Counseling, and Much More!

UNLIMITED HEALTHCARE SERVICES!

• $0 Consult for Virtual Urgent Care 24/7
• YOU CHOOSE your Deducated family Physician for Virtual Primary Care
• At-Home Labs
• $0 Co-Pay on many prescriptions and Discounts on others
• Condition Management
• On Demand Behavioral Health Counseling
• Financial and Legal Consultations

Be sure to register you and your family AFTER you complete this enrollment so you don't have any service charges!

___________________________________________
Recuro Health PRIMARY Care Package*

YES! Cover my entire household and myself for only $15 per paycycleNo thanks, I don't want this coverage
There's a Better Way to Pay for Healthcare with Sedera Medical Cost Sharing

Medical cost sharing is a peer-to-peer sharing of large, unexpected medical costs through a membership-based community. Members support one another's physical and financial health.
Need more information on this plan and how it works for you and your family? Simply check this box!

Show me the 4 minute video and plan details
A medical healthshare program, such as Sedera Medical Cost Sharing, is a non-profit community-based approach to managing healthcare costs. It is an alternative to health insurance.

Members of a healthshare program contribute funds monthly and share in each other's medical expenses. Sedera is there for the larger medical expenses, and members have the freedom to choose their own healthcare providers.
They offer cost-effectiveness, quick reimbursement, and additional services such as prescription discounts and maternity sharing.

Your IUA, (Initial Unshareable Amount) is $2500/Need per household. This means that you would be responsible for the first $2500 for any injury or illness before the community would help share in the cost of your care. We recommend partnering this with a good Hospital Indemnity plan that is in your offering. You also have a discounted rate when you enroll in Recuro Complete Virtual Primary Care!

Click here to view a member summary with more information.
Are you currently or have you used tobacco in the last 12 months?*

YesNo
Recuro Pass-Through
Tobacco Pass-Through
Age Band
Variables String
Sedera Variables Lookup
Member Only Rate per Paycycle
Member and Spouse Rate per Paycycle
Member and Child(ren) Rate per Paycycle
Member and Family Rate per Paycycle
Select your Sedera plan below!*

Member OnlyMember and SpouseMember and Child(ren)Member and FamilyNo thanks, I don't want a Sedera plan
Sedera Paycycle Premium Pass Through (HIDE)
Virtual URGENT CARE and EAP Program by Recuro Health

$0 Copays, No Waiting in a lobby, simply connect to a local doctor for minor illnesses and Injuries and go straight to a pharmacy if needed.
Need more information on this plan?

YES! Show me the 1 minute video.
Recuro Telehealth and EAP
• Unlimited Visits - $0 Consult
• Family coverage
• 24/7 Access
• $0 Consult on demand Behavioral Health
• Short-Term Mental Health Counseling
• Mental Health Advocacy
• Financial and Legal Consultations
Telehealth and Employee Assistance Program*

YES! Cover my entire household and myself for only $2.27 per paycycleNo thanks, I don't want this coverage
GREAT NEWS!

Your employer is paying 100% of this benefit for you and your family!
Minor Medical (MEC) Insurance

Having minimal essential health insurance, also known as minimum essential coverage (MEC), is important for several reasons.
Need more information on this plan and how it works for you and your family? Simply check this box!

Show me the 1 minute video and plan details
Having minimal essential health insurance, also known as minimum essential coverage (MEC), is important for several reasons:

1. Compliance with the Affordable Care Act (ACA): The ACA mandates that individuals must have MEC or pay a penalty when filing taxes. By having MEC, you fulfill this legal requirement and avoid potential financial penalties.

2. Access to Preventive Services: MEC plans typically cover a range of preventive services at no additional cost to you. These services include vaccinations, screenings, and check-ups that can help detect health issues early on and prevent more serious conditions from developing.

3. Protection Against High Medical Costs: Health insurance helps protect you from substantial financial burdens in the event of unexpected medical expenses. It ensures that you have coverage for hospital stays, surgeries, medications, and other healthcare services, reducing your out-of-pocket costs.

4. Better Healthcare Options: With MEC, you gain access to a network of healthcare providers who are part of your insurance plan. This gives you the flexibility to choose doctors, hospitals, and specialists within your network, making it easier to receive timely and coordinated care.

5. Peace of Mind: Having health insurance provides peace of mind, knowing that you have coverage for both routine and unexpected medical needs. It offers a safety net that can alleviate the stress and worry associated with healthcare costs, allowing you to focus on your well-being and that of your family.

It's important to note that while MEC provides basic coverage, it may not cover all healthcare services or provide comprehensive benefits. It's advisable to review the specific coverage details and limitations of any insurance plan you consider to ensure it meets your individual needs.

-----------------------------
SBMA Ultimate Plan / Paycycle Investment*

Employee Only / $36.70Employee + Spouse / $73.39Employee + Children / $73.39Employee + Spouse + Children / $110.08No thanks, I want to waive minor medical insurance

Part 3. - Your information

Please complete the fields below to confirm your elections. Your agent will process your applications, handle the underwriting, and protect you and your family with our flagship carriers!
If you are declining all coverage options, you will not see any fields below to fill in. Please continue to the next page by clicking "Next."
Date of Hire*

MonthDayYear
Date
YOUR Social Security Number (NO DASHES)*
This is required to enroll. Enter all numbers, no dashes, format. If waiving all coverage, please enter all zeros.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Gender*

MaleFemale
Are you covering a spouse?*

YesNo
Spouse's Legal Name*

First NameLast Name
Spouse's Date of Birth*

MonthDayYear
Date
Spouse's Gender*

MaleFemale
How many dependent children are you covering?*
If none, enter the number 0
Dependent #1 Full Name*

First NameLast Name
Dependent #1 Date of Birth*

MonthDayYear
Date
Dependent #1 Gender*
Dependent #2 Full Name*

First NameLast Name
Dependent #2 Date of Birth*

MonthDayYear
Date
Dependent #2 Gender*
Dependent #3 Full Name*

First NameLast Name
Dependent #3 Date of Birth*

MonthDayYear
Date
Dependent #3 Gender*
Dependent #4 Full Name*

First NameLast Name
Dependent #4 Date of Birth*

MonthDayYear
Date
Dependent #4 Gender*
Dependent #5 Full Name*

First NameLast Name
Dependent #5 Date of Birth*

MonthDayYear
Date
Dependent #5 Gender*
Dependent #6 Full Name*

First NameLast Name
Dependent #6 Date of Birth*

MonthDayYear
Date
Dependent #6 Gender*

Part 4. - Finalizing your enrollment

Below is a list of your elections and the TOTAL cost per paycycle. This does not factor in any employer contributions if applicable.
Assurity Group Term Life Insurance
Assurity Group Hospital Indemnity Insurance - $2,500 Benefit
Assurity Group Accident Expense Off Job Insurance
Assurity Group Accident Expense 24 Hour Insurance
Assurity Short-Term Disability
Assurity Lump Sum Critical Illness/Cancer Insurance
Assurity 3/6/9 Life Insurance
5Star Life Accident Coverage
5Star Life Group Hospital Insurance
5Star Life Insurance
5Star Life Insurance - Spouse Coverage
5Star Life Insurance - Dependent Coverage
5Star Life Total (Always Hidden)
Beam Dental Insurance
Beam Vision Insurance
Recuro Virtual Primary Care Services
Sedera Medical Cost Sharing
Recuro Telemedicine and EAP Program
SBMA MEC Health Insurance
Total of ALL plans and policies per paycycle. This does not calculate for any employer contributions if applicable. If you waived a benefit, the premium amount will be blank in that plan's field.
If you need to make changes, please click the "back" button at the bottom of this page. If you are satisfied with your elections, please complete this form.
Waiver acknowledgement:*

By marking this box, I acknowledge that I am waiving all or some of my benefit options this year. I understand that my benefits this year may be GUARANTEED ISSUE during this open enrollment period and that future enrollments may have underwriting/health questions.
Sign Here. Smile. Have a wonderful day!*

Clear
ATTENTION!

ASSURITY REQUIRES STATEMENTS OF HEALTH FOR HOSPITAL, CRITICAL ILLNESS, AND DISABILITY PLANS

DON'T CLOSE YOUR BROWSER AFTER SUBMITTING THIS FORM!

YOU WILL BE REDIRECTED TO the VERY SIMPLE STATEMENT OF HEALTH FORM AFTER YOU ARE FINISHED.
Should be Empty:

Covered Conditions	Payout
Heart Attack	100%
Coronary Artery Bypass Surgery	100%
Stroke	100%
Invasive Cancer (30-day waiting period)	100%
Non-Invasive Cancer (30-day waiting period)	25%
Skin Cancer (30-day waiting period)	$250/year
Kidney (Renal) Failure	100%
Major Organ Transplant	100%
Advanced Alzheimer's Disease	100%
Coma	100%
Paralysis	100%
Loss of Sight	100%
Loss of Speech	100%
Loss of Hearing	100%
Advanced Parkinson's Disease	100%
Benign Brain Tumor	100%
Occupational HIV	100%
Cardiopulmonary benefits included!	10%-50%

SAMPLE ----- Your enrollment has never been easier!

Part 1. - Required information

Part 2. - Your offerings, policy details, rates, and election options.

Group Term Life Insurance

Group Hospital Indemnity Insurance plus Observation with Critical Illness & Cancer

Group Accident Expense Insurance

Group Short Term Disability Insurance

Lump Sum Critical and Cancer Illness Insurance

"3/6/9" GROUP WHOLE LIFE INSURANCE

5Star Life Group Accident Insurance

5Star Life Group Hospital Indemnity Insurance

5STAR LIFE INSURANCE

DENTAL/VISION INSURANCE

DOES YOUR FAMILY NEED A PRIMARY CARE PHYSICIAN?

There's a Better Way to Pay for Healthcare with Sedera Medical Cost Sharing

Virtual URGENT CARE and EAP Program by Recuro Health

Minor Medical (MEC) Insurance

Part 3. - Your information

Part 4. - Finalizing your enrollment