Delta Foremost

= Required


1. Personal Information
Last Name First Name M.I. M/F Birthday Soc. Sec. #
Street Address City State Zip
Start Date Primary Phone Email Address
2. Health
Select Plan
Plan 1 ($4000 Ded.) Plan 2 ($2500 Ded.) Plan 3 ($1,500 Ded.) No Coverage
Select Coverage
Employee Only Employee & Spouse Employee & Children Employee & Family
Dependents  ➕ (add a dependent)
3. Dental
Select Plan
Coverage No Coverage
Select Coverage
Employee Only Employee & Spouse Employee & Children Employee & Family
Dependents  ➕ (add a dependent)
4. Vision
Select Plan
Coverage No Coverage
Select Coverage
Employee Only Employee & Spouse Employee & Children Employee & Family
Dependents  ➕ (add a dependent)
5. Disability - Must sign up at the time of hire.
Select Plan
Coverage No Coverage
Monthly Salary
Beneficiaries (Primary)  ➕ (add a primary beneficiary)
Last Name First Name Relation M/F Birthday Soc. Sec. # % ⓧ
Beneficiaries (Contingent)  ➕ (add a contingent beneficiary)
6. Life $15,000 Fixed Rate
Select Plan
Coverage No Coverage
Beneficiaries (Primary)  ➕ (add a primary beneficiary)
Last Name First Name Relation M/F Birthday Soc. Sec. # % ⓧ
Beneficiaries (Contingent)  ➕ (add a contingent beneficiary)

7. Life Variable Rate - Must sign up at the time of hire.
Select Plan
$100,000 Coverage $50,000 Coverage No Coverage
Beneficiaries (Primary)  ➕ (add a primary beneficiary)
Last Name First Name Relation M/F Birthday Soc. Sec. # % ⓧ
Beneficiaries (Contingent)  ➕ (add a contingent beneficiary)

You must elect coverage on yourself before electing coverage on your spouse or children.
You (Employee) will be the default beneficiary for spouse and child coverage.
Spouse Coverage
Yes $25,000 No Coverage
Last Name First Name Birthday Soc. Sec. #
Children Coverage
Yes $10,000 each No Coverage
Children  ➕ (add children)
Last Name First Name Birthday Soc. Sec. # ⓧ

Applicant Signature Date

By typing your name above and submitting this form, the same legal status is held as a handwritten signature.