New Hire Benefits Intake

Do you have family members who work for St. Louis County or Arrowhead Regional Corrections?

Will you be covering a spouse on life, medical, vision or dental benefits?

Yes, I am married and will cover my spouse on at least one of these benefits

I am married but I will not cover my spouse on these benefits

I am not married

Spouse's Gender

Male

Female

Location of Marriage

Street Address
Street Address 2
County	State
Postal Code	Country

Spouse SSN (no dashes)

Will you be covering children on any benefits?

Yes

No

Child's Name

First Name
Middle Name
Last Name
Suffix

Child's Gender

Male

Female

Child's Location of Birth

Street Address
Street Address 2
County	State
Postal Code	Country

I would like to enroll my child in these benefits:

Medical

Vision

Dental

Life

I have more children to enroll

Child Two's Relationship to You:

Child Two's Date of Birth (Do not guess/estimate)

Month

-

Day

-

Year

Child Two's SSN (no dashes)

Is Child Two a full-time Student?

Yes

No

Pre-Kindergarten Age

Child Three's Name:

First Name
Middle Name
Last Name
Suffix

Child Three's Gender

Male

Female

Child Three's Location of Birth:

Street Address
Street Address 2
County	State
Postal Code	Country

I would like to enroll Child Three in these benefits:

Medical

Vision

Dental

Life

I have more than 3 children to enroll

Child Four's Relationship to You:

Child Four's Date of Birth (Do not guess/estimate)

Month

-

Day

-

Year

Child Four's SSN (no dashes)

Is Child Four a full time student?

Yes

No

Pre-kindergarten Age

Child Five's Name:

First Name
Middle Name
Last Name
Suffix

Child Five's Gender

Male

Female

Child Five Location of Birth:

Street Address
Street Address 2
County	Birth
Postal Code	Country

I would like to enroll Child Five in these benefits:

Medical

Vision

Dental

Life

Duluth	(218) 726-2000
Ely	(218) 365-2399
Hibbing	(218) 312-8100
Virginia	(218) 749-7100
Toll Free	(800) 450-9777

New Hire Benefits Intake

New Hire Benefit Elections

Coverage and Cost Information is posted at www.stlouiscountymn.gov/benefits

Spouse Life: You are the beneficiary, coverage is limited to half the amount you elect on yourself, amounts over $30,000 will require medical review/approval, if your spouse works for SLC/ARC you cannot enroll them in spousal life

Spouse Life: You are the beneficiary, coverage is limited to half the amount you elect on yourself, amounts over $30,000 will require medical review/approval, if your spouse works for SLC/ARC you cannot enroll them in spousal life

Child Life: You are the beneficiary, coverage applies to all eligible children (under 18 or under 24 if full -time student)

Note: If your spouse works for SLC or ARC, you cannot enroll them in a benefit that they enrolled in themself

Note: If your child works for SLC or ARC, you cannot enroll them in a benefit that they enrolled in themself

If you have more than 5 children, click Next and call 218-725-5056

Do not click NEXT until you have entered all dependents.

You are not done until you click SUBMIT

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St. Louis County Offices