Benefit Enrollment Form

To activate your benefits, please complete and submit the required form. This step is necessary to initiate your coverage and ensure your benefits are ready when you need them.

1. Member Information

First Name *

Middle Name

Last Name *

Date of Birth *

Social Security Number *

Gender *

Phone *

Email *

Important: Please ensure you use the same email address you provided during your purchase of healthcare benefits. This helps us verify your account and provide seamless service.

Street Address *

Street Address 2

City *

Zipcode *

State *

Attestations

Must be able to answer “Yes” to both inquiries to be eligible for policy coverage.

I am currently employed or self-employed. *

I affirm no person(s) seeking coverage within the individual or family plan has been diagnosed or tested positive for the HIV/AIDS virus. *

Primary Beneficiary

Beneficiary Full Name *

Beneficiary Relationship *

Spouse

Add a Spouse?

Yes No

Spouse First Name *

Spouse Middle Name

Spouse Last Name *

Spouse Date of Birth *

Spouse Gender *

Spouse Social Security Number *

Dependent Information

(max age 26)

Add Dependents?

Yes No

Dependent 1

Dep1 First Name *

Dep1 Middle Name

Dep1 Last Name *

Dep1 Date of Birth *

Dep1 Gender *

Dep1 Relationship *

Dependent 2

Dep2 First Name

Dep2 Middle Name

Dep2 Last Name

Dep2 Date of Birth

Dep2 Gender

Dep2 Relationship

Dependent 3

Dep3 First Name

Dep3 Middle Name

Dep3 Last Name

Dep3 Date of Birth

Dep3 Gender

Dep3 Relationship

Dependent 4

Dep4 First Name

Dep4 Middle Name

Dep4 Last Name

Dep4 Date of Birth

Dep4 Gender

Dep4 Relationship

Signature

Please review all the information above carefully to ensure it is accurate. Correct details are essential for processing your request and providing the best service possible.

Signature Full Name *

Signature Date *

I agree to the Policy Terms *

I attest that all the information within the application is accurate. *

Hidden

Confidentiality and Privacy: Member information is utilized for the enrollment process in LifeExec's health and wellness benefits program.

We prioritize the confidentiality of member data, which is only shared with benefit partners to facilitate the provision of healthcare coverage and support services.

Signature Individual