MEC PLAN ENROLLMENT PORTAL
EZ Staffing & Affiliate Companies
Effective Date: 01/01/2021
PLAN INFORMATION - ENGLISH
PLAN INFORMATION - ESPANOL
SOB - BRONZE
SOB - SILVER
Rx FORMULARY
EZ Staffing Enrollment Portal
Plan Information
Company Name
*
Select One
EZ Staffing
Bay Personnel
MCK Personnel
Tomorrow Personnel
MV Plan Selection
*
Select One
Bronze MV
Silver MV
Bronze MV
Single
Single + Spouse
Single + Child(ren)
Family
Silver MV
Single
Single + Spouse
Single + Child(ren)
Family
Plan Start Date
*
Coverage will begin on the first of the selected month.
March
April
May
June
July
August
September
October
November
December
Employee Information
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Social Security Number
*
Date of Birth
*
Date Format: MM slash DD slash YYYY
Gender
*
Male
Female
Email
*
Phone
*
Dependent 1 Information
Name
*
First
Last
Social Security Number
*
Date of Birth
*
Date Format: MM slash DD slash YYYY
Gender
*
Male
Female
Relationship
*
Spouse
Child
Domestic Partner
Step-Child
Email
Add Another Dependent?
Yes
Dependent 2 Information
Name
*
First
Last
Social Security Number
*
Date of Birth
*
Date Format: MM slash DD slash YYYY
Gender
*
Male
Female
Relationship
*
Spouse
Child
Domestic Partner
Step-Child
Email
Add Another Dependent?
Yes
Dependent 3 Information
Name
*
First
Last
Social Security Number
*
Date of Birth
*
Date Format: MM slash DD slash YYYY
Gender
*
Male
Female
Relationship
*
Spouse
Child
Domestic Partner
Step-Child
Email
Add Another Dependent?
*
Yes
No
Dependent 4 Information
Name
*
First
Last
Social Security Number
*
Date of Birth
*
Date Format: MM slash DD slash YYYY
Gender
*
Male
Female
Relationship
*
Spouse
Child
Domestic Partner
Step-Child
Email
Add Another Dependent?
*
Yes
No
Dependent 5 Information
Name
*
First
Last
Social Security Number
*
Date of Birth
*
Date Format: MM slash DD slash YYYY
Gender
*
Male
Female
Relationship
*
Spouse
Child
Domestic Partner
Step-Child
Email
