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Benemax® - Enrollment Connection
✓ Employee Personal Information
Please complete this enrollment form for yourself and any dependents for whom you are electing coverage. Upon validation by your employer's representative, your enrollment will be processed.

After you have completed all of the enrollment sections, you will have an opportunity to modify your entries before finalizing your elections.

VBM Code*
Program *
Social Security Number*
Create Username*
Create Password*
**Password must be of at least 8 characters and should contain at least one upper case letter or one lower case letter.
Employee First Name*
Employee Last Name*
Suffix
Address
Street Address Address Line 2 City State/Province/Region Zip Code Country
Phone
Mobile
Email*
Gender*
Male
Female
Date of Birth*
Date of Hire*
Job Title*
Salary
$
       
  ** Please write down your username and password for future reference.
Save & Continue...
✓ Dependents
Please click Save & Continue if you are not adding dependents.

Dependent
First Name*
Last Name*
Suffix
Address Same as Employee*
Yes
No
New Address
Street Address Address Line 2 City State/Province/Region Zip Code       
Gender*
Male
Female
Relationship
Spouse
Former Spouse
Domestic Partner
Child
Date of Birth*
Waive SSN
Check to Waive SSN
Social Security Number*
Add Dependent #2 Yes

First Name*
Last Name*
Suffix
Address Same as Employee*
Yes
No
New Address
Street Address Address Line 2 City State/Province/Region Zip Code        
Gender*
Male
Female
Relationship
Spouse
Former Spouse
Domestic Partner
Child
Date of Birth*
Waive SSN
Check to Waive SSN
Social Security Number*
Add Dependent #3 Yes
First Name*
Last Name*
Suffix
Address Same as Employee*
Yes
No
New Address
Street Address Address Line 2 City State/Province/Region Zip Code      
Gender*
Male
Female
Relationship
Spouse
Former Spouse
Domestic Partner
Child
Date of Birth*
Waive SSN
Check to Waive SSN
Social Security Number*
Add Dependent #4 Yes
First Name*
Last Name*
Suffix
Address Same as Employee*
Yes
No
New Address
Street Address Address Line 2 City State/Province/Region Zip Code      
Gender*
Male
Female
Relationship
Spouse
Former Spouse
Domestic Partner
Child
Date of Birth*
Waive SSN
Check to Waive SSN
Social Security Number*
Add Dependent #5 Yes
First Name*
Last Name*
Suffix
Address Same as Employee*
Yes
No
New Address
Street Address Address Line 2 City State/Province/Region Zip Code     
Gender*
Male
Female
Relationship
Spouse
Former Spouse
Domestic Partner
Child
Date of Birth*
Waive SSN
Check to Waive SSN
Social Security Number*
Add Dependent #6 Yes
First Name*
Last Name*
Suffix
Address Same as Employee*
Yes
No
New Address
Street Address Address Line 2 City State/Province/Region Zip Code       
Gender*
Male
Female
Relationship
Spouse
Former Spouse
Domestic Partner
Child
Date of Birth*
Waive SSN
Check to Waive SSN
Social Security Number*
Add Dependent #7 Yes
First Name*
Last Name*
Suffix
Address Same as Employee*
Yes
No
New Address
Street Address Address Line 2 City State/Province/Region Zip Code      
Gender*
Male
Female
Relationship
Spouse
Former Spouse
Domestic Partner
Child
Date of Birth*
Waive SSN
Check to Waive SSN
Social Security Number*
Add Dependent #8 Yes
First Name*
Last Name*
Suffix
Address Same as Employee*
Yes
No
New Address
Street Address Address Line 2 City State/Province/Region Zip Code      
Gender*
Male
Female
Relationship
Spouse
Former Spouse
Domestic Partner
Child
Date of Birth*
Waive SSN
Check to Waive SSN
Social Security Number*
Add Dependent #9 Yes
First Name*
Last Name*
Suffix
Address Same as Employee*
Yes
No
New Address
Street Address Address Line 2 City State/Province/Region Zip Code       
Gender*
Male
Female
Relationship
Spouse
Former Spouse
Domestic Partner
Child
Date of Birth*
Waive SSN
Check to Waive SSN
Social Security Number*
Add Dependent #10 Yes
First Name*
Last Name*
Suffix
Address Same as Employee*
Yes
No
New Address
Street Address Address Line 2 City State/Province/Region Zip Code       
Gender*
Male
Female
Relationship
Spouse
Former Spouse
Domestic Partner
Child
Date of Birth*
Waive SSN
Check to Waive SSN
Social Security Number*
First Name*
Last Name*
Suffix
Address Same as Employee*
Yes
No
New Address
Street Address Address Line 2 City State/Province/Region Zip Code      
Gender*
Male
Female
Relationship
Child
Spouse
Former Spouse
Domestic Partner
Date of Birth*
Waive SSN
Check to Waive SSN
Social Security Number*
Add Dependent #12 Yes
First Name*
Last Name*
Suffix
Address Same as Employee*
Yes
No
New Address
Street Address Address Line 2 City State/Province/Region Zip Code       
Gender*
Male
Female
Relationship
Child
Spouse
Former Spouse
Domestic Partner
Date of Birth*
Waive SSN
Check to Waive SSN
Social Security Number*
Add Dependent #12 Yes
First Name*
Last Name*
Suffix
Address Same as Employee*
Yes
No
New Address
Street Address Address Line 2 City State/Province/Region Zip Code       
Gender*
Male
Female
Relationship
Child
Spouse
Former Spouse
Domestic Partner
Date of Birth*
Waive SSN
Check to Waive SSN
Social Security Number*
Save & Continue...
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✓ Health Plan

Your Health Plan: What would you like to do?
Enroll
Make a Change
Terminate Coverage
Waive Coverage

Reason for Transaction*
Open Enrollment
New Hire
Loss of Spouse Coverage
Loss of Coverage- COBRA Expiration
Loss of Coverage- Divorce
Loss of Coverage-Death
Date of Loss of Coverage*
Reason for Transaction*
Add New Dependent - Birth or Adoption
Add New Dependent - Marriage
Add New Dependent - Dependent Loss of Coverage
Date of Change*
Reason for Transaction*
Loss of Employment
Loss of Eligibility
Alternative Coverage Availability
COBRA Termination
Date of Loss or Change of Coverage*
Reason For Waiver*
Name of the Group*
Insurance Company Associated*
Please Note
Once you choose to waive coverage, you may not enroll unless it is open enrollment time again or you have a qualifying change of events.
     
Please Note
Once you choose to waive coverage, you may not enroll unless it is open enrollment time again or you have a qualifying change of events.
Please Note
Once you choose to waive coverage, you may not enroll unless it is open enrollment time again or you have a qualifying change of events.
Reason for Transaction*
Open Enrollment
New Hire

Dependents

Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person



Gold - HMO
$92.31 per payroll

View Plan Details
Silver - HMO
$34.62 per payroll

View Plan Details
Bronze - HMO
$13.85 per payroll

View Plan Details
Gold - PPO
$161.54 per payroll

View Plan Details
Silver - PPO
$103.85 per payroll

View Plan Details
Bronze - PPO
$34.62 per payroll

View Plan Details
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✓ Dental Plan
Your Dental Plan: What would you like to do?
Enroll
Make a Change
Terminate Coverage
Waive Coverage
Reason for Transaction*
Open Enrollment
New Hire
Loss of Spouse Coverage
Loss of Coverage- COBRA Expiration
Loss of Coverage- Divorce
Loss of Coverage-Death
Date of Loss of Coverage*
Reason for Transaction*
Add New Dependent - Birth or Adoption
Add New Dependent - Marriage
Add New Dependent - Dependent Loss of Coverage
Date of Change*
Reason for Transaction*
Loss of Employment
Loss of Eligibility
Alternative Coverage Availability
COBRA Termination
Date of Loss or Change of Coverage*
Reason For Waiver*
Name of the Group*
Insurance Company Associated*
Please Note
Once you choose to waive coverage, you may not enroll unless it is open enrollment time again or you have a qualifying change of events.
     
Please Note
Once you choose to waive coverage, you may not enroll unless it is open enrollment time again or you have a qualifying change of events.
Please Note
Once you choose to waive coverage, you may not enroll unless it is open enrollment time again or you have a qualifying change of events.
Reason for Transaction*
Open Enrollment
New Hire

Dependents

Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person



Benedent 1500 w/Guardian Network
$4.62 per payroll

View Plan Details
Save & Continue...
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✓ Vision Plan
Your Vision Plan: What would you like to do?
Enroll
Make a Change
Terminate Coverage
Waive Coverage
Reason for Transaction*
Open Enrollment
New Hire
Loss of Spouse Coverage
Loss of Coverage- COBRA Expiration
Loss of Coverage- Divorce
Loss of Coverage-Death
Date of Loss of Coverage*
Reason for Transaction*
Add New Dependent - Birth or Adoption
Add New Dependent - Marriage
Add New Dependent - Dependent Loss of Coverage
Date of Change*
Reason for Transaction*
Loss of Employment
Loss of Eligibility
Alternative Coverage Availability
COBRA Termination
Date of Loss or Change of Coverage*
Reason For Waiver*
Name of the Group*
Insurance Company Associated*
Please Note
Once you choose to waive coverage, you may not enroll unless it is open enrollment time again or you have a qualifying change of events.
     
Please Note
Once you choose to waive coverage, you may not enroll unless it is open enrollment time again or you have a qualifying change of events.
Please Note
Once you choose to waive coverage, you may not enroll unless it is open enrollment time again or you have a qualifying change of events.
Reason for Transaction*
Open Enrollment
New Hire

Dependents

Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person
Cover This Person
Do Not Cover This Person


Vision Plan
$4.07 per payroll

View Plan Details
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✓ HFSA 2021

For Gold Participants and those not covered under a Non-HSA Qualified Health Plan

I authorize my employer to reduce my gross paycheck in equal installments based on the annual election below by the following pre-tax amounts to fund flexible spending account(s).  For reimbursement of eligible medical, dental, and vision expenses.  (Maximum election $2,750 per plan year)

By enrolling in FSA, I understand that:

  • These contributions to my flexible spending account(s) will be deducted from my paycheck on a per pay period basis.   
  • I understand that this authorization cannot be changed during the plan year unless I experience a change in family status as established by IRS regulations. 
  • I understand that any unused amounts remaining in the dependent daycare assistance account at the end of the plan year and grace period will be forfeited in accordance with the rules and regulations established by the IRS.
  • I understand that if I leave the company before the end of the plan year I have 90 days from the date of termination in which to submit claims that were incurred before my termination date.



Contribute
Do Not Contribute





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✓ DCA 2021

I authorize my employer to reduce my gross paycheck in equal installments based on the annual election below by the following pre-tax amounts to fund flexible spending account(s).  For reimbursement of employment related dependent daycare expenses.  (Maximum election $5,000 per plan year if filing jointly; $2,500 if married and filing separately)

By enrolling in DCA, I understand that:

  • These contributions to my flexible spending account(s) will be deducted from my paycheck on a per pay period basis.   
  • I understand that this authorization cannot be changed during the plan year unless I experience a change in family status as established by IRS regulations. 
  • I understand that any unused amounts remaining in the dependent daycare assistance account at the end of the plan year and grace period will be forfeited in accordance with the rules and regulations established by the IRS.
  • I understand that if I leave the company before the end of the plan year I have 90 days from the date of termination in which to submit claims that were incurred before my termination date.



Contribute
Do Not Contribute





Save & Continue...
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✓ LP-FSA 2021

For Silver & Bronze Participants Only.

I authorize my employer to reduce my gross paycheck in equal installments based on the annual election below by the following pre-tax amounts to fund flexible spending account(s).  For reimbursement of eligible vision and dental expenses.  (Maximum election $2,750 per plan year)

By enrolling in LFSA, I understand that:

  • These contributions to my flexible spending account(s) will be deducted from my paycheck on a per pay period basis.   
  • I understand that this authorization cannot be changed during the plan year unless I experience a change in family status as established by IRS regulations. 
  • I understand that any unused amounts remaining in the dependent daycare assistance account at the end of the plan year and grace period will be forfeited in accordance with the rules and regulations established by the IRS.
  • I understand that if I leave the company before the end of the plan year I have 90 days from the date of termination in which to submit claims that were incurred before my termination date.



Contribute
Do Not Contribute





Save & Continue...
Back