Employee Benefits - COBRA Compliance NEWLY COVERED EMPLOYEE COMPLETE THE FOLLOWING Your Name Employer Name Email Add additional email address(es) Additional Email (if adding multiple emails, separate by commas.) Employee's Name Gender -- Select --FemaleMale Employee's Social Security Home Address Apt/Unit No. City State -- Select State --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--District of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana Islands Postal Code Date of Birth Date of Hire Date Insurance Benefits Start? Send Notice In -- Select --EnglishSpanish Plans Enrolled In MedicalDentalVisionChiropractic / OtherFlexible Spending Plan Name Of Medical Plan: Medical Coverage: Employee OnlyEmployee & SpouseEmployee & ChildEmployee & ChildrenEmployee & Family Name Of Dental Plan: Dental Coverage: Employee OnlyEmployee & SpouseEmployee & ChildEmployee & ChildrenEmployee & Family Name Of Vision Plan: Vision Coverage: Employee OnlyEmployee & SpouseEmployee & ChildEmployee & ChildrenEmployee & Family Name Of Other Plan: Other Coverage: Employee OnlyEmployee & SpouseEmployee & ChildEmployee & ChildrenEmployee & Family Monthly Amount of FSA CONTRIBUTION Do they have Covered Children? YesNo Do they have a Covered Spouse or Domestic Partner? YesNo Full Names and Birth Dates of All Covered Children Spouse Name Spouse Date of Birth Does Either Spouse or Children Have a Different Home Address? If yes, please show address in additional notes. -- Select --YesNo Please Include Any Additional Notes Δ Request a Quote For... AUTO & VEHICLE HOME & PROPERTY BUSINESS SERVICES EMPLOYEE BENEFITS About UA My UA Portal Request A Quote Employee Benefits COBRA HR Link OSHA Newsletter Payments Contact Us