SAMPLE EXPRESSENROLL WEEKLY

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.
This video is important and short. Thanks for spending 2 minutes on this.
Guarantee issue is perpetual at open enrollment only and for new hires.

Important note: The waiver of pre-existing conditions on some plans is for a company's FIRST ENROLLMENT ONLY and new hires.

If this is your company's first enrollment with these benefits, TAKE ADVANTAGE of this one time opportunity.
I have watched this video and I acknowledge that the guarantee issue applies only during my company's open enrollment period. The waiver for pre-existing conditions is available only at the first open enrollment, except for newly hired employees. If I choose to waive coverage now, I may need to answer health questions for future coverage, and pre-existing conditions will not be waived.

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)
Show Assurity Group Life Products (HIDE)

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.Format: (000) 000-0000.
Gender

Your Household Information

If you've chosen to cover your spouse and/or any dependents, we need to collect some information about them!
If you do not see anything below, that means the plans you have enrolled do not include coverage for your spouse and/or any dependents. You can go to the next page to finalize your enrollment.
Are you covering a spouse?
Spouse's Legal Name

First NameLast Name
Spouse's Date of Birth

MonthDayYear
Date
Spouse's Gender
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

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
5Star Life Insurance
5Star Life Insurance - Spouse Coverage
5Star Life Insurance - Dependent Coverage
5Star Life Total (Always Hidden)
Beam Dental Insurance
Beam Vision Insurance
Lyric Virtual Primary Care Services
Lyric Telemedicine
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:
Sign Here. Smile. Have a wonderful day!
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%

Your Enrollment has never been easier!