Employee Self-Funded Health Plan Questionnaire

The confidential information provided on this form will be used to determine appropriate premium rates for the applicable employer group. You cannot be declined for coverage based on the information provided on this form, and you will not be individually charged a higher premium based on your responses. No information on this form will be disclosed to your employer.

Shortly you will be directed to an enrollment and health questionnaire. To start the enrollment process and begin the questionnaire please follow the steps below.


1. Please enter your first and last name.

2. Select the name of your employer from list list below.

3. Now choose if you want to enroll into your employers health coverage plan. You can choose to enroll or choose to waive your option to enroll.