APPLICATION FORM

1. Please fill in all the information below that is relevant to your application for Healthcare Insurance. Be sure to click "Submit Form" button only once.
   The * denotes a required field (if for some reason you can not fill out the required field please enter "N/A" in that space and enter the details of why in the "comments section") PLEASE ONLY CLICK ON SUBMIT BUTTON ONCE.

   *First Name
   *Last Name
   Middle Initial
   *Title
   Social Security # (no dashes or spaces)
   *Date of  Birth
   *Date Of Hire
   *Gender
   *US Mailing Street Address
   * US Mailing City
   *US Mailing State
   *US Mailing Zip
   *International Mailing Street Address
   * International Mailing City
   International Mailing Province/State
   *International Mailing Country
   International Mailing Postal Code
   Working Country
   *Country of Residence
   *Country of Citizenship
   International Main Work Phone
   US Phone
   Other Contact Phone (Cell)
   *E-mail
   Comments or Additional Contact Information

2. If you have Dependents who will be covered by the PSC-Health Plan, please provide their contact information:

   Dependent 1 First Name
   Dependent 1 Last Name
   Dependent 1 Middle Initial
   Dependent 1 Date of Birth
   Dependent 1 Relation to Employee
   Dependent1 Social Security Number
   Dependent 1 US Street Address
   Dependent 1 US City
   Dependent 1 US State
   Dependent1 Zip Code
   Dependent 1 International Address
   Dependent 1 International State
   Dependent1 International Country
   DEPENDENT NUMBER 2 INFORMATION
   Dependent 2 First Name
   Dependent 2 Last Name
   Dependent 2 Middle Initial
   Dependent 2 Date of Birth
   Dependent 2 Relation to Employee
   Dependent 2 Social Security Number
   Dependent 2 US Street Address
   Dependent 2 US City
   Dependent 2 US State
   Dependent 2 Zip Code
   Dependent 2 International Address
   Dependent 2 International State
   Dependent 2 International Country
   DEPENDENT NUMBER 3 INFORMATION
   Dependent 3 First Name
   Dependent 3 Last Name
   Dependent 3 Middle Initial
   Dependent 3 Date of Birth
   Dependent 3 Relation to Employee
   Dependent 3 Social Security Number
   Dependent 3 US Street Address
   Dependent 3 US City
   Dependent 3 US State
   Dependent 3 Zip Code
   Dependent 3 International Address
   Dependent 3 International State
   Dependent 3 International Country
   DEPENDENT NUMBER 4 INFORMATION
   Dependent 4 First Name
   Dependent 4 Last Name
   Dependent 4 Middle Initial
   Dependent 4 Date of Birth
   Dependent 4 Relation to Employee
   Dependent 4 Social Security Number
   Dependent 4 US Street Address
   Dependent 4 US City
   Dependent 4 US State
   Dependent 4 Zip Code
   Dependent 4 International Address
   Dependent 4 International State
   Dependent 4 International Country
   DEPENDENT NUMBER 5 INFORMATION
   Dependent 5 First Name
   Dependent 5 Last Name
   Dependent 5 Middle Initial
   Dependent 5 Date of Birth
   Dependent 5 Relation to Employee
   Dependent 5 Social Security Number
   Dependent 5 US Street Address
   Dependent 5 US City
   Dependent 5 US State
   Dependent 5 Zip Code
   Dependent 5 International Address
   Dependent 5 International State
   Dependent 5 International Country
   DEPENDENT NUMBER 6 INFORMATION
   Dependent 6 First Name
   Dependent 6 Last Name
   Dependent 6 Middle Initial
   Dependent 6 Date of Birth
   Dependent 6 Relation to Employee
   Dependent 6 Social Security Number
   Dependent 6 US Street Address
   Dependent 6 US City
   Dependent 6 US State
   Dependent 6 Zip Code
   Dependent 6 International Address
   Dependent 6 International State
   Dependent 6 International Country
   DEPENDENT NUMBER 7 INFORMATION
   Dependent 7 First Name
   Dependent 7 Last Name
   Dependent 7 Middle Initial
   Dependent 7 Date of Birth
   Dependent 7 Relation to Employee
   Dependent 7 Social Security Number
   Dependent 7 US Street Address
   Dependent 7 US City
   Dependent 7 US State
   Dependent 7 Zip Code
   Dependent 7 International Address
   Dependent 7 International State
   Dependent 7 International Country
   DEPENDENT NUMBER 8 INFORMATION
   Dependent 8 First Name
   Dependent 8 Last Name
   Dependent 8 Middle Initial
   Dependent 8 Date of Birth
   Dependent 8 Relation to Employee
   Dependent 8 Social Security Number
   Dependent 8 US Street Address
   Dependent 8 US City
   Dependent 8 US State
   Dependent 8 Zip Code
   Dependent 8 International Address
   Dependent 8 International State
   Dependent 8 International Country
   BY CLICKING THE SUBMIT BUTTON BELOW I CERTIFY THAT I HAVE READ AND AGREE TO THE DISCLAIMER INFORMATION ON THE PREVIOUS HEALTH PLAN DESCRIPTION WEB PAGE (CLICK TO REVIEW THIS INFORMATION)

    
Please click the above Submit Form button only once. It is a large form so can take several seconds to process. When the processing is complete (perhaps a minute or longer), you will receive a "Thank You" response. At this point your application will have been sent to us for our review and action.