How To Enroll In Supplemental Insurance
Print the application for the carrier of your choice and fill out your basic information, select the plan(s)
that you would like to have for Open Enrollment and sign the application.
(You can even use your pdf editor and do it electronically)
Do not worry about codes, etc. we just need your basic information, selections and signature.
Print the Payroll Deduction Authorization (P.D.A.), put your name and sign your payroll card.
Copy of PDA will be forwarded back to you with all codes filled out.
Turn in to Brad Shattuck or email your application and payroll deduction card to firstname.lastname@example.org
Questions? Brad's cellular #813-293-7489