Note: The act of inputting your name below serves as a general electronic signature and is legally binding. Please read the applicable statements below:
Plan Administrator / Employee: I acknowledge (by typing my name below) that the information contained in this application is accurate and true to my knowledge.
Plan Administrator: I have the permission of the Employee to share the information and that the Employee was informed and is eligible to participate in the Smartin Benefits PHSP.
Employee: I confirm participation and eligibility to participate in the Smartin Benefits PHSP.
Now, type the Captcha characters in the space provided below. If you cannot see the characters, click on the image to refresh with a new set of characters
Once you completed all the required fields, click on the Submit button. A summary email will be sent to the email address listed in the form. We will contact you if we have any questions.