AAOA Employer e-Services

* Denotes required field

Employee Information

Please fill in or correct the fields highlighted below.

First Name:

Birth Date:

Some dates are invalid. Format (MM/DD/YYYY)
{{badEmployeeDate}}

Middle Name:

SSN:

SSN length is invalid.
{{badEmployeeSSN}}

SSN is already used.

Last Name:

Marital Status:

Address:

Job Title:

City:

Hire Date:

State:

Class:

Zip:

Part Time to Full Time?:

Conversion Date

County:

E-Mail:

Loss of Coverage?:

Event Date

Phone Number:

Effective Date: {{employee.employee.calcEffDate}}

Gender:

FSA?:

Yes / No

Annual Contribution
Starting Payroll Date
Payroll Deduction
Total Payroll Deductions

Dependent Daycare?:

Yes / No

Daycare Annual Contribution
Daycare Payroll Date
Daycare Payroll Deduction
Daycare Total Payroll Deductions

Primary Care Physician Type:

PCP Name:
PCP Number:

Height:

Weight:

Currently Working Full Time:
Plan To Keep Other Coverage:
Other Insurance Policy #:
Name of Other Insurance:
Covered by Medicare/Medicaid:
Medicare/Medicaid Effective Date:

* Denotes required field

Dependents

Begin entering the first dependent's information into the boxes below.
Click 'Add more...' to add another dependent (not available when Spouse or Domestic Partner only selected).
Click 'Clear Row' to clear all filled in fields and errors from a given row.
You must enter at least one dependent.
Blank lines are OK.
Select the plans that each dependent will be using.

Dependent SSN has already been used.

SSN Length is invalid.
{{badDependentSSN}}

SSN is already used.

Some dates are invalid.
{{badDependentDate}}

One or more dependents needs to have 1 or more plans selected.

Relationship	First Name	Last Name	M.I.	Birthdate	SSN	Gender	Height	Weight

Please select the desired plans
Medical Vision Dental

Working Full Time:

Plan To Keep Other Coverage:

Other Insurance Policy #:

Name of Other Policy:

Covered by Medicare/Medicaid:

Medicare/Medicaid Effective Date:

* Denotes required field

Group Life Insurance Beneficiary Designation

Please designate a primary life insurance beneficiary. Optionally, enter a life insurance contingent as well.

Please fill in or correct the fields highlighted below.

Beneficiary

{{life.type}} Beneficiary

First Name:
Last Name:
SSN:
Birthdate:
Relationship:
Address:
City:
State:
Zip:

Confirm and Submit

Please double-check the information you have entered into the form before submitting.

Application Agreement (Group Administrator)

I Agree that this application contains correct information to the best of my ability.

To submit, please type your registered e-mail address in the box below then click the submit application button.

Please enter your registered e-mail address.

Errors Encountered.

Online Administration - Add Employee (and Dependent(s))

Add Administration

{{plan.plan_type}} Coverage

Add Administration

Employee Information

Dependents

Group Life Insurance Beneficiary Designation

Beneficiary

{{life.type}} Beneficiary

Confirm and Submit

Application Agreement (Group Administrator)