Employee Data Form

Company Name:
Address:
City & State:
Zip Code:
Phone: (        )
FAX: (        )
Contact Person:

Please complete and fax to First HSA at (610) 678-6818.

Medical Coverage Codes:
E- Employee Only
C- Employee and Child
S- Employee and Spouse
F- Full Family
N- No Covered Selected

 

Employee Name:

Sex

DOB/Age

Life/DI
Benefit Level

Medical Coverage Code

Number of Children