Common Contracts
1 similar Enrollment Form contracts
Peak1 Administration | 7600 Mineral Drive, Suite 450 | Coeur d'Alene, Idaho 83815 healthbridge@mypeak1.com | Phone: 855.814.7565 | Fax: 855.495.3669Enrollment Form • June 2nd, 2014
PARTICIPANT: Please complete all items listed below.Carefully complete all sections. Missing information often results in enrollment delays, which could affect your ability to file claims and receive reimbursement of your qualified healthcare expenses and insurance premiums.Fully complete participant, spouse and dependent information (federally required information) Enter participant contact informationSign and date Hold Harmless AgreementMake a copy of your completed form for your records Return original to your employer’s payroll/benefits office EMPLOYER: Please fully complete this sectionMissing information often results in delays. This could affect your employee’s ability to file claims and receive reimbursement for their expenses and insurance premiums. Please make a copy of this completed form for your records.Enrolling employee is:Active or Separating/retiring on:Specified Participant Effective Date (optional):You may specify the enrolling employee's Participant effective date, no
