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ENROLL or WAIVE Coverage

Enter Enrollment Information on our Secure Site
*Required fields

Employee #

First Name

Last Name

Gender * Required

Male

Female

Select a date

Social Security #

Phone

Email

Street Address

City

Region/State/Province

Postal / Zip code

CHOOSE PLAN(s)

Date of Hire

Cigna MEDICAL Options (select only one) * Required

High $1500

Mid $3000

Base $5000

Waive Medical Coverage

Medical Coverage Level * Required

Employee Only

Employee + Spouse

Employee + Child(ren)

Family

Acknowldegement: *

I understand that if I waive medical benefits, I am not eligible for a federally subsidized plan, as my employer offers an affordable, comprehensive plan and will need to repay the IRS any/all subsidies they have received.

Principal DENTAL * Required

Principal DPPO

Waive Dental Coverage

Dental - Add Dependent Coverage *

Employee Only

EE + Spouse

EE + Child(ren)

EE + Family

Principal VISION * Required

UHC Vision

Waive Vision Coverage

Vision - Add Dependent Coverage *

Employee Only

EE + Spouse

EE + Child(ren)

EE + Family

Add Dependent Information (Who else will be getting benefits?)

Dependent 1

Spouse

Child

Dependent 1 Date of Birth

Dependent 1 SS#

Male

Female

Dependent 2

Spouse

Child

Dependent 2 Date of Birth

Dependent 2 SS#

Male

Female

Dependent 3

Spouse

Child

Dependent 3 Date of Birth

Dependent 3 SS#

Male

Female

Dependent 4

Spouse

Child

Dependent 4 Date of Birth

Dependent 4 SS#

Male

Female

Dependent 5

Spouse

Child

Dependent 5 Date of Birth

Dependent 5 SS#

Male

Female

Principal Life Insurance Beneficiary Information

Life Beneficiary 1

Beneficiary 1 Social Security

Percentage to Beneficiary 1

Relationship 1

Life Beneficiary 2

Beneficiary 2 Social Security

Percentage to Beneficiary 2

Relationship 2

Life Beneficiary 3

Beneficiary 3 Social Security

Percentage to Beneficiary 3

Relationship 3

Life Beneficiary 4

Beneficiary 4 Social Security

Percentage to Beneficiary 4

Relationship 4

Life Beneficiary 5

Beneficiary 5 Social Security

Percentage to Beneficiary 5

Relationship 5

TOTAL = 100%

If you wish to cover additional dependents or add more beneficiaries, please contact Bold Lion at (212) 931-6313.

Your Signature

Thanks for enrolling!
Please be aware that you will receive a confirmation email, however, it does NOT include your elections. It is recommended that you make note of the benefits you elected.

WANT VOLUNTARY LIFE INSURANCE? CLICK HERE

bottom of page

ENROLL or WAIVE Coverage

Enter Enrollment Information on our Secure Site *Required fields

CHOOSE PLAN(s)

Add Dependent Information (Who else will be getting benefits?)

Principal Life Insurance Beneficiary Information

TOTAL = 100%

If you wish to cover additional dependents or add more beneficiaries, please contact Bold Lion at (212) 931-6313.

Thanks for enrolling! Please be aware that you will receive a confirmation email, however, it does NOT include your elections. It is recommended that you make note of the benefits you elected.

Enter Enrollment Information on our Secure Site
*Required fields

Thanks for enrolling!
Please be aware that you will receive a confirmation email, however, it does NOT include your elections. It is recommended that you make note of the benefits you elected.