Employee Insurance Enrollment Forms | William J. King & Associates Insurance Services, Inc.

Enrollment Request Form

Your Information * Name:
Phone:
Fax:
E-mail:
Group Name:
Group Number:

Employee Information Effective Term. Date:

Employee Name:
Empl. ID#:
Reason:

Changes Requested Enrollment / New Hire

Fax enrollment form for processing.
*Note: Please refer to the Employee Eligibility Page to confirm that enrollment is possible.

Please cancel the above employee from my group plan

Coverage change for an existing employee.
Please call to confirm that changes can be made.
Fax Coverage Change Form / Enrollment form to us for processing.
*Note: There must be a qualifying event in order to make changes or add dependents onto a policy (i.e. birth, adoption, marriage, spouse lost other coverage, etc.). Please refer to your Employee Eligibility Page to confirm that changes can be made.

New employee has not received his cards

Please get back to me on the following issue:

There were some problems with the information you have submitted. Listed below are the fields that need attention.