The LMS Group

Employee Add/Deletion Form

State:

Add or 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: