Employer Enrollments Upload your enrollment form below. Name of Employer*Name of Employee*Date of Birth* MM DD YYYY Date of Hire* MM DD YYYY Social Security Number*Job Title*Weekly or Hourly Wage*Number of Hours Worked Per Week*Employee Class IF Applicable:Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Voluntary Benefits Section/Supplemental Life InsuranceEmployee Life AmountTobacco Use Smoker Non-Smoker Spousal Life Yes No Spousal Life AmountChildren Yes No Special Requests/OtherFile UploadAccepted file types: doc, docx, pdf.