Employment Information

Hire Date Employment Classification Shareholder/Partner Associate Exempt Salaried Employee Nonexempt Staff Employee

Personal Information. . .
About Yourself

First Name Middle Initial Last Name

Street Address or Box Number
                                         City     State      ZIP

Your Birth Date

Are you a smoker ?   Yes    No (Not smoked within last 6 months)

Marital Status Single Married Previously Married Children Eligible for Insurance?

...About Your Spouse

Name SSN Birth Date

Employer Health Insurance Carrier

Is your spouse a smoker?   Yes    No

...About Your Children

Other health insurance which covers your child(ren):
(Spouse, former spouse, etc.)

Group Health Insurance
Please click in the selection box for your choice of Medical Plan and the coverage you want.
To Review the Plan Details, click here

Life Insurance
You are eligible for two times your annual salary in group term life insurance, paid by the Firm. Please designate a beneficiary or beneficiaries for your group term life insurance.

Group Universal Life Insurance

I Enroll in the American General voluntary Group Universal Life Insurance

I Decline to Enroll

<<<link to premium chart and medical history questionnaire>>>

Disability Insurance

Optional Employee-paid Short Term Disability

Long Term Disability
Coverage is paid by the Firm. Click here to review details of eligibility and coverage.

Retirement Plan 401(k)

To review the plan details, click here

I Enroll in the 401(k) Plan and will contribute 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 11% 12% 13% 14% 15%

I Decline Enrollment

I choose allocation of my contribution to the funds as checked below:

401(k) Beneficiary(ies)

If you are married, your spouse must be your beneficiary unless s/he has filed a written waiver with the Plan Administrator. If you have filed the waiver or if you are not married, please complete the beneficiary designation below.

Optional Cancer Insurance