ENROLLMENT

EMAIL ADDRESS: dave@cafroagency.com
PHONE: 860-779-DAVE 

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ENTER APPLICANT'S INFORMATION BELOW

Applicant Employer *

First Name & Middle Initial *

First

Last

Date of Birth mm/dd/yyyy *

Date of Hire mm/dd/yyyy *

Applicant Email *

Applicant Phone *

Applicant social security number xxx-xx-xxxx *

Applicant Street Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Medical Coverage Requested

• yes
• no

Dental Coverage Requested

• yes
• no

Vision Coverage Requested

• yes
• no

Select an Optional Plan (specify plan in field below)

• yes
• no

Plan:

Effective Date of Coverage Requested mm/dd/yyyy

IF YOU ARE MARRIED, ENTER YOUR SPOUSE'S INFORMATION BELOW

Spouse Employer

First Name & Middle Initial

First

Last

Spouse Date of Birth mm/dd/yyyy

Spouse Gender

• male
• female

Spouse Email

Spouse Phone

Spouse social security number xxx-xx-xxxx

Spouse Coverage: Medical Coverage Requested

• yes
• no

Spouse Coverage: Dental Coverage Requested

• yes
• no

Spouse Coverage: Vision Coverage Requested

• yes
• no

ENTER YOUR CHILD 1 INFORMATION BELOW

Child 1 First Name & Middle Initial

First

Last

Child 1 Date of Birth mm/dd/yyyy

Child 1 Gender

• male
• female

Child 1 social security number

Child 1 Coverage: Medical Coverage Requested

• yes
• no

Child 1 Coverage: Dental Coverage Requested

• yes
• no

Child 1 Coverage: Vision Coverage Requested

• yes
• no

ENTER YOUR CHILD 2 INFORMATION BELOW

Child 2 First Name & Middle Initial

First

Last

Child 2 Date of Birth mm/dd/yyyy

Child 2 Gender

• male
• female

Child 2 social security number xxx-xx-xxxx

Child 2 Coverage: Medical Coverage Requested

• yes
• no

Child 2 Coverage: Dental Coverage Requested

• yes
• no

Child 2 Coverage: Vision Coverage Requested

• yes
• no

ENTER YOUR CHILD 3 INFORMATION BELOW

Child 3 First Name & Middle Initial

First

Last

Child 3 Date of Birth mm/dd/yyyy

Child 3 Gender

• male
• female

Child 3 social security number xxx-xx-xxxx

Child 3 Coverage: Medical Coverage Requested

• yes
• no

Child 3 Coverage: Dental Coverage Requested

• yes
• no

Child 3 Coverage: Vision Coverage Requested

• yes
• no

ENTER YOUR CHILD 4 INFORMATION BELOW

Child 4 First Name & Middle Initial

First

Last

Child 4 Date of Birth mm/dd/yyyy

Child 4 Gender

• male
• female

Child 4 social security number xxx-xx-xxxx

Child 4 Coverage: Medical Coverage Requested

• yes
• no

Child 4 Coverage: Dental Coverage Requested

• yes
• no

Child 4 Coverage: Vision Coverage Requested

• yes
• no

Submit