Auto Enrollment Requirements Checklist
Please complete this checklist to confirm all requirements for auto enrollment are met.
Applicant Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Organization Name (if applicable)
Role/Position
Select Program or Service for Enrollment
*
Please Select
Employee Benefits Program
Student Enrollment
Insurance Plan
Membership Auto Renewal
Other
Checklist: Please confirm each requirement for auto enrollment is completed.
*
Completed application form submitted
Proof of eligibility provided
Supporting documents uploaded
Terms and conditions reviewed
No outstanding obligations
Consent to communications given
Other (please specify)
Upload Supporting Documents (if required)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Date of Submission
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Comments or Notes
Submit Checklist
Should be Empty: