Florida Employers Association

Membership Application
(Groups of four or more)

* denotes a required field

*Business Name:		Tax ID:
Address:
*City:	*State:	*ZIP Code:
*Phone:	Fax:
Email Address:
*Contact Person:		Date:
*Are you a Nicholas Group client?
Total # of Employees:	# of Employees interested in FEA:
*Requested Effective Date:
Please Select the Programs of Interest: Dependent Hospital Cash Benefit Coverage COBRA
Requested Payment Option: Monthly Credit Card Monthly Bank Draft Annual Direct Bill Annual Credit Card Annual Bank Draft

BENEFIT+ Member List

Please input all the names of the employees who will be accepting FEA membership and also whether they're choosing the additional hospital benefit dependent coverage.

Employee Name	Hospital Dependent Coverage?	Employee Name	Hospital Dependent Coverage?

Note: All benefits end upon termination of employment.

This form must be completed for all employees accepting FEA membership, whether they are WAIVING group health coverage or not.

If you have any questions, or need assistance,
please call (877) BEN-PLUS (236-7587).

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