Client Login
CONTACT US
RHS Sales & Administration
800-548-7677, Ext. 121
707-525-4370
jnacol@rhs.org
Employee Enrollment and Change Form
COMPANY INFORMATION
Company name
*
Type of business
Business address
street
city
state
--
AA
AE
AL
AK
AP
AR
AZ
CA
CO
CT
DC
DE
FL
GU
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
zip
Contact name
*
Contact phone
*
Contact e-mail
*
Requested coverage
Medical
Dental
Vision
Requested effective date
----
January
February
March
April
May
June
July
August
September
October
November
December
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1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
----
2010
2009
2008
2007
2006
2005
Employees
Number of employees
Number enrolling in plan
Group coverage in past 180 days?
Yes
No
Current carrier
Current monthly premium
$
Employer premium contributions
For employees
%
For dependents
%
EMPLOYEE CENSUS
List the number of employees (EE) in each category
Age
EE only
EE/spouse
EE/children
EE/family
0-29
30-39
40-49
50-54
55-59
60-64
65+
*
required field
