CAUTION: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.
CAUTION: Employee must complete sections 1 – 18. Please print or type. Review plan brochure before completing this Enrollment Form. BI-WEEKLY & MONTHLY
NOTE: Eligible employees – all active full-time employees of participating employers who are under the age of 70