Health Insurance Survey Form Step 1 of 5 20% Employee Name* First Last Do you wish to enroll in Brighton's health insurance plan?* Yes No Employee Date of Birth* MM slash DD slash YYYY Employee Gender* Employee Zip Code* Do you wish to enroll a spouse on the policy?*YesNo SPOUSE INFOSpouse Name* First Last Spouse Date of Birth* MM slash DD slash YYYY Spouse's Gender* Spouse's Zip Code* Do you wish to enroll children on the policy?*YesNoChild # 1 Name* First Last Child #1 Date of Birth* MM slash DD slash YYYY Child #1 Gender* Child #1 Zip Code* If you have additional children to be enrolled, please list their names, dates of birth, gender and zip code here:PhoneThis field is for validation purposes and should be left unchanged.
