SunTechPros, Inc.

Health Insurance Enrollment Details

Name of Employee:      

Address in USA:      
     

Home Phone:       Cell:       Email:      

Details First Name Last Name Gender DOB SSN #

(M / F) MM/DD/YYY
Self                              

Spouse                              

Child                              

Child                              

Child                              

Please specify the coverage you are interested in. Check the box for all 3 Options

E – Employee Only, ES – Employee & Spouse – EF Employee and Family (Including Children)

1. Health Insurance : E ES EF
2. Dental Insurance (Optional): E ES EF
3. Vision Insurance (Optional): E ES EF

Insurance Effective From:      

Previous Insurance Details (if earlier covered by another insurance company):

Name of Insurance Company:      

Please Tick One

I accept health insurance coverage as per above details

I decline health insurance coverage as I am already covered through personal insurance / spouse’s
insurance

     
(Signature of Employee)
Date:      

Note: Write your name on top of “Signature of Employee” and it would be considered as your consent.