Employer Name: *

Todays Date: *

EMPLOYEE INFORMATION

Full Legal Name: *

Date of Birth *

Phone *

Email *

Address *

Street Address *

City *

State *

Country *

Postal Code *

EMPLOYERCARE BASE PLAN ENROLLMENT

OPTIONAL DIRECT PRIMARY CARE (DPC) ENROLLMENT (Optional where available)

Direct Primary Care is an optional add-on service at $40 per enrolled household member. Maximum $160 per household for the first four enrolled members. Dependents 5–8 are included at no additional cost. Dependents beyond eight are $40 each. Services available only in participating areas. (Once you choose I elect Direct Primary Care (DPC), you will receive a form to enroll your family member.)

Enroll In DPC

I elect Direct Primary Care (DPC)

I decline Direct Primary Care (DPC)

MEMBERSHIP & PARTICIPATION AGREEMENT

EmployerCare is a voluntary employee benefit membership program and is not insurance. Participation begins on the effective date listed above and continues month-to-month unless terminated as outlined below.

Individual employee participation will end immediately upon termination of employment. If the employer remains an active participating group, individual employee participation may otherwise be discontinued with sixty (60) days notice, subject to employer policies and payroll timing.

Employer group participation may be terminated with ninety (90) days written notice. Employer agrees not to materially reduce enrolled participation for the purpose of avoiding the required group termination notice period.

EmployerCare provides access to third-party providers and service partners. EmployerCare does not provide medical care and is not responsible for medical decisions, treatment outcomes, or actions of third-party providers.

Direct Primary Care services, if elected, are available only in participating service areas and may vary by location.

I agree to the Terms & Conditions provided by the company, including monthly recurring billing, cancellation policy, and that this is not insurance but an access-based service. By providing my phone number, I consent to receive recurring text messages from the business. Message and data rates may apply. Message frequency varies.

Employee's Signature *

Clear

Date Signed: