The LMS Group
Employee Add/Deletion Form
State:
Add or Remove?
ADD
REMOVE
*
= field required for removal
All fields required for addition
Company Name:
Email Address:
Employee Name:
*
Gender:
Coverage:
SS Number
*
Occupation
Add/Remove Effective Date
*
Employee's DOB:
Street Address:
City:
State:
Zip:
Home Phone:
Beneficiary Name:
Beneficiary Relationship:
Spouse Name:
Spouse's DOB:
Spouse SS Number
Child1 Name:
Child2 Name:
Child2's DOB:
