MEC PLAN ENROLLMENT PORTAL
Delta Building Services
MEC PLAN INFORMATION - ENGLISH
INFORMACION DE PLAN MEC - ESPANOL
Delta Building Services Enrollment Portal
Plan Information
Choose Plan
*
MEC VPC
Excel MEC + Hospital Indemnity
MEC VPC
Single
Single + Spouse
Single + Child(ren)
Family
Excel MEC + Hospital Indemnity
*
Single
Single + Spouse
Single + Child(ren)
Family
Effective Date
*
Please choose which month your coverage will begin. The Effective Date will be the 1st of the selected month.
January
February
March
April
May
June
July
August
September
October
November
December
Primary Information
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Social Security Number
*
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Email
*
Dependent 1 Information
Name
*
First
Last
Social Security Number
*
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Relationship
*
Spouse
Child
Domestic Partner
Step-Child
Add Another Dependent?
Yes
Dependent 2 Information
Name
*
First
Last
Social Security Number
*
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Relationship
*
Spouse
Child
Domestic Partner
Step-Child
Add Another Dependent?
Yes
Dependent 3 Information
Name
*
First
Last
Social Security Number
*
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Relationship
*
Spouse
Child
Domestic Partner
Step-Child
Add Another Dependent?
*
Yes
No
Dependent 4 Information
Name
*
First
Last
Social Security Number
*
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Relationship
*
Spouse
Child
Domestic Partner
Step-Child
Add Another Dependent?
*
Yes
No
Dependent 5 Information
Name
*
First
Last
Social Security Number
*
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Relationship
*
Spouse
Child
Domestic Partner
Step-Child
