MEC PLAN ENROLLMENT PORTAL
MEXICUE
MEC PLAN INFORMATION
Mexicue Enrollment Portal
Plan Information
MEC Plan Selection
*
Excel MEC
Superior MEC
Superior + National High MEC
Excel MEC
Single
Single + Spouse
Single + Child(ren)
Family
Superior MEC
Single
Single + Spouse
Single + Child(ren)
Family
Superior + National High MEC
Single
Single + Spouse
Single + Child(ren)
Family
Plan Start Date (Month)
*
Coverage will begin on the 1st of the month
January
February
March
April
May
June
July
August
September
October
November
December
Plan Start Date (Year)
*
2021
2022
Employee 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
