Benefits Enrollment | City of Lordsburg

Employee Information

To protect your personal information, this app does NOT store your data. Please complete the enrollment in one session and press SUBMIT to securely transmit your information to our encrypted servers. Thank you!

First Name *

Middle Name

Last Name *

Suffix

Date of Birth *

Age: -- years

Social Security Number *

Full 9-digit SSN — encrypted in transit, never stored

Physical Address *

Mailing address is the same as physical address

Email Address *

Phone Number *

Sex *

Male

Female

Tobacco Use *

Yes

In the last 12 months have you used tobacco or nicotine-based products or substitutes such as patches or gum?

Employment Information

Your current employment details

Date of Employment *

Hours per Week *

Annual Salary *

Dependents

Add dependents to unlock additional coverage tiers

Employee Only coverage displays UNTIL you add dependents to unlock additional coverage options and premiums.

Select Your Benefits

Choose coverage for each plan below

Beneficiary Designation

Not yet completed

Designate who receives your benefits. At least one primary beneficiary is required.

Enrollment Summary

Review your benefit selections

Total Per-Paycheck Deduction

$0.00

Bi-weekly (26 pay periods)

NOTICE TO CONSUMER

This is a limited benefits health plan. The benefits provided are supplemental to, and not a substitute for, major medical coverage, even in combination with other limited benefits plans. To apply for an individual or small-group major medical plan, please visit the website of the New Mexico Health Insurance Exchange at www.bewellnm.com or call 1-833-862-3935 (TTY: 711). Or contact your benefits advisor, Nelson Harris, at (602) 669-4954 for a custom tailored plan.

Please complete the following before submitting: