Enrollment Form
Ready to get started? Submit our easy enrollment form below. In about two business days, you’ll receive an email from the EASE system with instructions to finish your coverage application and upload any required documents.
Please Note:
- This enrollment form is for independent contractors only.
- All enrollments and payments must be made by the 15th of the month prior to the effective date.
- This plan requires submission of marriage and birth certificates for any legal dependents on the plan (If these are not submitted with the initial enrollment, claim payment for the dependent can be delayed up to 30 days after submission.