Temp New Hire Benefit Enrollment

Child's Name

First Name
Middle Name
Last Name
Suffix

Child's Gender

Male
Female

Location of Birth

Street Address
Street Address 2
County	State
Postal Code	Country

I would like to enroll this child in these benefits:

Medical
Vision
Dental

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)

Child Three's Name:

First Name
Middle Name
Last Name
Suffix

Child Three's Gender

Male
Female

Location of Child 3's Birth:

Street Address
Street Address 2
County	State
Postal Code	Country

I would like to enroll child 3 in these benefits:

Medical
Vision
Dental

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)

Child Five's Name:

First Name
Middle Name
Last Name
Suffix

Child Five's Gender

Male
Female

Location of Child 5's Birth:

Street Address
Street Address 2
County	Birth
Postal Code	Country

I would like to enroll child 5 in these benefits:

Medical
Vision
Dental

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

Temp New Hire Benefit Enrollment

New Hire Benefit Elections

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

Spouse Life: You are the beneficiary, amounts over $30,000 (7 or more increments) 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

Have more than 5 children?

You are not finished until you click SUBMIT

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