National General

Employee Enrollment Health App

Step 1 of 7

EMPLOYER INFORMATION ( must be completed )

You must complete this form in its entirety in order for you or your dependents to be covered under the health insurance plan. If you are waiving coverage for yourself or your dependents, it musts be clearly indicated on this form. If you do not complete this form in its entirety for yourself or your dependents at least 5 business days prior to the effective date , you or your dependents maybe not be eligible for coverage until the next open enrollment period.

TO BE COMPLETED BY EMPLOYEE( if applying or waiving coverage )

A- EMPLOYEE ( Primary Applicant )

National General Benefits Solutions markets products underwritten and issued by National Health Insurance Company, Time Insurance Company, Integon National Insurance Company, and Integon Indemnity Corporation.