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Phone: 866-253-2273

Extended Family Enrollment

Spouses and dependents of current members are already eligible for Patient Care. If you are eligible to enroll an extended family member, please complete the following information to enroll them. Fields marked with an * are required.

Name of Employer*:
Employee Full Name*:
Employee Phone*:

Enrollment requests processed by the 15th day of the month will be effective the 15th of that month. Enrollment requests processed on the 16th day or later will be effective the 1st of the month.

For example: John Deer fills out our online enrollment form on January 12th. His order is processed on the 12th and his subscription effective date is January 15th. If John had enrolled on the 16th, his subscription effective date would be February 1st.

Please provide the following information for each extended family member.

Last Name*:
First Name*:
Middle Initial:
Social Security No.*:
Date of Birth*:
Address*:
Address 2:
City*:
State*:
Zip*:
Email:
Day Phone*:
Night Phone*:
Fax:
Relationship to Employee:


Primary Insurance
Insurance Company Name*:
Plan/Coverage Type:
HMO   PPO   Medicare   Other  
Group Number*:
Subscriber Number*:
Effective Date*:


Secondary Insurance (if any)
Insurance Company Name:
Plan/Coverage Type:
HMO   PPO   Medicare   Other  
Group Number:
Subscriber Number:
Effective Date:


Do you have an immediate need? Do you want an Advocate to contact you?
Yes   No