Health Insurance Participation

The Home Care Family is considering offering health insurance for its employees. In order to secure a quote, we are asking all employees if they would or would not be interested in joining a health insurance program. At this point, we do not know the cost to employees. If we decide to offer a health insurance plan, the coverage would begin in 2020.

ALL EMPLOYEES, please complete the form below by Friday, November 22nd. This is not an agreement to enroll or not enroll.

Employee Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Gender

Home Zip Code

Requested Coverage

Spouse and Children

If your requested coverage includes spouse or children, please enter their name, date of birth, gender, home and work zip codes

Health Insurance Participation

Health Insurance Participation

On Call 24/7

281-888-0385