Enrollment – Akron-Westfield Benefits Directory

Personal Information - Employee

Please confirm your information to proceed with benefits election.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

SSN(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Are you a Tobacco User?

Please signify if you have used tobacco in the last 12 Months

Tobacco User(Required)

Yes

Dependents

Please signify if you have dependents

Do you have dependents?(Required)

Yes

Dependent One - Information

Dependent 1 Full Name(Required)

Dependent 1 Date of Birth(Required)

MM slash DD slash YYYY

Dependent 1 Gender(Required)

Dependent 1 Relation(Required)

Do you have a second dependent?(Required)

Yes

Dependent Two - Information

Dependent 2 Full Name(Required)

Dependent 2 Date of Birth(Required)

MM slash DD slash YYYY

Dependent 2 Gender(Required)

Dependent 2 Relation(Required)

Do you have a third dependent?(Required)

Yes

Dependent Three - Information

Dependent 3 Full Name(Required)

Dependent 3 Date of Birth(Required)

MM slash DD slash YYYY

Dependent 3 Gender(Required)

Dependent 3 Relation(Required)

Beneficiary - Information

Beneficiary Full Name(Required)

Beneficiary Date of Birth(Required)

MM slash DD slash YYYY

Beneficiary Gender(Required)

Beneficiary Relation(Required)

Hospital Indemnity

Please select the tier (Employee, Employee and Spouse, Employee and Child, Family) you wish to enroll in. If you DO NOT want this product, please select the "I choose to waive" option.

Hospital(Required)

Employee

Employee and Spouse

Employee and Child

Family

I choose to waive Hospital Indemnity

Plan Type

Accident Insurance

Please select the tier (Employee, Employee and Spouse, Employee and Child, Family) you wish to enroll in. If you DO NOT want this product, please select the "I choose to waive" option.

Accident(Required)

Employee

Employee and Spouse

Employee and Child

Family

I choose to waive Accident

Critical Illness

Please select the tier (Employee, Employee and Spouse, Employee and Child, Family) and the benefit amount you wish to enroll in. If you DO NOT want this product, please select the "I choose to waive" option.

Critical Illness(Required)

Employee

Employee and Spouse

Employee and Child

Family

I choose to waive Critical Illness

Critical Illness Amount

Medical Plans - HealthPartners $1000, $3000, $5000

Please select the tier (Employee, Employee and Spouse, Employee and Child, Family) you wish to enroll in. If you DO NOT want this product, please select the "I choose to waive" option.

$1,000 Plan - Health Partners(Required)

Employee

Employee and Spouse

Employee and Child

Family

I choose to waive this plan

$3,000 Plan - Health Partners(Required)

Employee

Employee and Spouse

Employee and Child

Family

I choose to waive this plan

$5,000 Plan - Health Partners(Required)

Employee

Employee and Spouse

Employee and Child

Family

I choose to waive this plan

Dental & Vision

Please select the tier (Employee, Employee and Spouse, Employee and Child, Family) you wish to enroll in. If you DO NOT want this product, please select the "I choose to waive" option.

Dental(Required)

Employee

Employee and Spouse

Employee and Child

Family

I choose to waive Dental

Vision(Required)

Employee / EE + Child

EE+ Spouse / Family

I choose to waive Vision

Voluntary life

Please select the amount of life insurance you wish to enroll in. If you DO NOT want this product, please select the "I choose to waive" option.

Voluntary Life Insurance(Required)

Employee

I choose to waive Voluntary Life

Voluntary Life Amount

Voluntary Life insurance is guaranteed-issue up till $50,000. If you require more, please consult your Benefits Advisor

Short-Term Disability

Please select the amount of disability insurance you wish to enroll in. If you DO NOT want this product, please select the "I choose to waive" option.

Disability

Employee

I choose to waive Disability

Paycheck Protection Amount

Disability pays you up to 60% of your annual wages. You can select between 40%, 50% and 60%

Finish

Once you are completed with your elections please press submit.

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Signature

Claims Assistance

Enroll in your 2025 Benefit Offers

Personal Information - Employee

Are you a Tobacco User?

Dependents

Dependent One - Information

Dependent Two - Information

Dependent Three - Information

Beneficiary - Information

Hospital Indemnity

Accident Insurance

Critical Illness

Medical Plans - HealthPartners $1000, $3000, $5000

Dental & Vision

Voluntary life

Short-Term Disability

Finish

Benefits 101