Array ( [0] => Field_SSN Object ( [Field_ID] => Employee_SSN [Field_Name] => Employee_SSN [Field_Title] => SSN [Field_Type] => SSN [Field_Data] => [Field_Class] => [Field_Required] => 1 [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [1] => Field_Text Object ( [Field_MaxLength] => 9 [Field_Size] => 9 [Field_ID] => Unit_ID [Field_Name] => Unit_ID [Field_Title] => Unit [Field_Type] => String [Field_Data] => [Field_Class] => [Field_Required] => 1 [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [2] => Field_Text Object ( [Field_MaxLength] => 50 [Field_Size] => 20 [Field_ID] => Employee_Last_Name [Field_Name] => Employee_Last_Name [Field_Title] => Last Name [Field_Type] => String [Field_Data] => [Field_Class] => [Field_Required] => 1 [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [3] => Field_Text Object ( [Field_MaxLength] => 50 [Field_Size] => 20 [Field_ID] => Employee_First_Name [Field_Name] => Employee_First_Name [Field_Title] => First Name [Field_Type] => String [Field_Data] => [Field_Class] => [Field_Required] => 1 [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [4] => Field_Text Object ( [Field_MaxLength] => 1 [Field_Size] => 1 [Field_ID] => Employee_MI [Field_Name] => Employee_MI [Field_Title] => Middle Initial [Field_Type] => String [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [5] => Field_Select Object ( [Field_Options] => Array ( [M] => Male [F] => Female ) [Field_BlankText] => Select One [Field_ID] => Employee_Sex [Field_Name] => Employee_Sex [Field_Title] => Sex [Field_Type] => Select [Field_Data] => [Field_Class] => [Field_Required] => 1 [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [6] => Field_Date Object ( [Field_Format] => INPUT [Field_MinYear] => 1900 [Field_MaxYear] => 2022 [Field_ID] => Employee_Date_of_Birth [Field_Name] => Employee_Date_of_Birth [Field_Title] => Date of Birth [Field_Type] => Date [Field_Data] => [Field_Class] => [Field_Required] => 1 [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [7] => Field_Text Object ( [Field_MaxLength] => 255 [Field_Size] => 20 [Field_ID] => Employee_Home_Address [Field_Name] => Employee_Home_Address [Field_Title] => Address [Field_Type] => String [Field_Data] => [Field_Class] => [Field_Required] => 1 [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [8] => Field_Text Object ( [Field_MaxLength] => 50 [Field_Size] => 20 [Field_ID] => Employee_City [Field_Name] => Employee_City [Field_Title] => City [Field_Type] => String [Field_Data] => [Field_Class] => [Field_Required] => 1 [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [9] => Field_Select Object ( [Field_Options] => Array ( [AL] => ALABAMA [AK] => ALASKA [AZ] => ARIZONA [AR] => ARKANSAS [CA] => CALIFORNIA [CO] => COLORADO [CT] => CONNECTICUT [DE] => DELAWARE [DC] => DISTRICT OF COLUMBIA [FL] => FLORIDA [GA] => GEORGIA [HI] => HAWAII [ID] => IDAHO [IL] => ILLINOIS [IN] => INDIANA [IA] => IOWA [KS] => KANSAS [KY] => KENTUCKY [LA] => LOUISIANA [ME] => MAINE [MD] => MARYLAND [MA] => MASSACHUSETTS [MI] => MICHIGAN [MN] => MINNESOTA [MS] => MISSISSIPPI [MO] => MISSOURI [MT] => MONTANA [NE] => NEBRASKA [NV] => NEVADA [NH] => NEW HAMPSHIRE [NJ] => NEW JERSEY [NM] => NEW MEXICO [NY] => NEW YORK [NC] => NORTH CAROLINA [ND] => NORTH DAKOTA [OH] => OHIO [OK] => OKLAHOMA [OR] => OREGON [PA] => PENNSYLVANIA [RI] => RHODE ISLAND [SC] => SOUTH CAROLINA [SD] => SOUTH DAKOTA [TN] => TENNESSEE [TX] => TEXAS [UT] => UTAH [VT] => VERMONT [VA] => VIRGINIA [WA] => WASHINGTON [WV] => WEST VIRGINIA [WI] => WISCONSIN [WY] => WYOMING ) [Field_BlankText] => Select One [Field_ID] => Employee_State [Field_Name] => Employee_State [Field_Title] => State [Field_Type] => Select [Field_Data] => [Field_Class] => [Field_Required] => 1 [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [10] => Field_Zip Object ( [Field_ID] => Employee_Zip [Field_Name] => Employee_Zip [Field_Title] => Zip [Field_Type] => Zip [Field_Data] => [Field_Class] => [Field_Required] => 1 [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [11] => Field_Phone Object ( [Field_ID] => Employee_Home_Phone [Field_Name] => Employee_Home_Phone [Field_Title] => Home Phone [Field_Type] => Phone [Field_Data] => [Field_Class] => [Field_Required] => 1 [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [12] => Field_Phone Object ( [Field_ID] => Employee_Work_Phone [Field_Name] => Employee_Work_Phone [Field_Title] => Work Phone [Field_Type] => Phone [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [13] => Field_Text Object ( [Field_MaxLength] => 5 [Field_Size] => 5 [Field_ID] => Employee_Extension [Field_Name] => Employee_Extension [Field_Title] => Ext [Field_Type] => String [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [14] => Field_Email Object ( [Field_ID] => Employee_Email [Field_Name] => Employee_Email [Field_Title] => Email [Field_Type] => Email [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [15] => Field_Date Object ( [Field_Format] => INPUT [Field_MinYear] => 1900 [Field_MaxYear] => 2022 [Field_ID] => Current_Hire_Date [Field_Name] => Current_Hire_Date [Field_Title] => Hire Date [Field_Type] => Date [Field_Data] => [Field_Class] => [Field_Required] => 1 [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [16] => Field_Select Object ( [Field_Options] => Array ( ) [Field_BlankText] => Select One [Field_ID] => Medical_Option [Field_Name] => Medical_Option [Field_Title] => Medical Option [Field_Type] => Select [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [17] => Field_Select Object ( [Field_Options] => Array ( [1] => 1 - Employee [2] => 2 - Employee + Spouse [3] => 3 - Employee + Child [4] => 4 - Employee + Children [5] => 5 - Family ) [Field_BlankText] => Select One [Field_ID] => Medical_Coverage_Type [Field_Name] => Medical_Coverage_Type [Field_Title] => Coverage Type [Field_Type] => Select [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [18] => Field_Date Object ( [Field_Format] => INPUT [Field_MinYear] => 1900 [Field_MaxYear] => 2022 [Field_ID] => Medical_Effective_Date [Field_Name] => Medical_Effective_Date [Field_Title] => Effective Date [Field_Type] => Date [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [19] => Field_Select Object ( [Field_Options] => Array ( ) [Field_BlankText] => Select One [Field_ID] => Dental_Option [Field_Name] => Dental_Option [Field_Title] => Dental Option [Field_Type] => Select [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [20] => Field_Select Object ( [Field_Options] => Array ( [1] => 1 - Employee [2] => 2 - Employee + Spouse [3] => 3 - Employee + Child [4] => 4 - Employee + Children [5] => 5 - Family ) [Field_BlankText] => Select One [Field_ID] => Dental_Coverage_Type [Field_Name] => Dental_Coverage_Type [Field_Title] => Coverage Type [Field_Type] => Select [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [21] => Field_Date Object ( [Field_Format] => INPUT [Field_MinYear] => 1900 [Field_MaxYear] => 2022 [Field_ID] => Dental_Effective_Date [Field_Name] => Dental_Effective_Date [Field_Title] => Effective Date [Field_Type] => Date [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [22] => Field_Select Object ( [Field_Options] => Array ( ) [Field_BlankText] => Select One [Field_ID] => Vision_Option [Field_Name] => Vision_Option [Field_Title] => Vision Option [Field_Type] => Select [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [23] => Field_Select Object ( [Field_Options] => Array ( [1] => 1 - Employee [2] => 2 - Employee + Spouse [3] => 3 - Employee + Child [4] => 4 - Employee + Children [5] => 5 - Family ) [Field_BlankText] => Select One [Field_ID] => Vision_Coverage_Type [Field_Name] => Vision_Coverage_Type [Field_Title] => Coverage Type [Field_Type] => Select [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [24] => Field_Date Object ( [Field_Format] => INPUT [Field_MinYear] => 1900 [Field_MaxYear] => 2022 [Field_ID] => Vision_Effective_Date [Field_Name] => Vision_Effective_Date [Field_Title] => Effective Date [Field_Type] => Date [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [25] => Field_Select Object ( [Field_Options] => Array ( [Y] => Yes [N] => No ) [Field_BlankText] => Select One [Field_ID] => Is_Cobra [Field_Name] => Is_Cobra [Field_Title] => Is Member a COBRA Enrollee? [Field_Type] => Select [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [26] => Field_Date Object ( [Field_Format] => INPUT [Field_MinYear] => 1900 [Field_MaxYear] => 2022 [Field_ID] => Cobra_Event_Date [Field_Name] => Cobra_Event_Date [Field_Title] => COBRA Event Date [Field_Type] => Date [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [27] => Field_Select Object ( [Field_Options] => Array ( [] => NONE [1] => Termination (involuntary-ARRA) [E] => Termination (involuntary) [8] => Termination (voluntary) [2] => Reduction of Hours [A] => Reduction of Hours - Involuntary [B] => Reduction of Hours - Involuntary-ARRA [3] => Death of Employee [4] => Divorce or Legal Separation [5] => Cessation of Dependent Status [6] => Employee Eligible for Medicare [7] => Retired [9] => Other [C] => Open Enrollment [D] => Eligible for Other Coverage ) [Field_BlankText] => Select One [Field_ID] => Cobra_Event_Type [Field_Name] => Cobra_Event_Type [Field_Title] => COBRA Event Type [Field_Type] => Select [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [28] => Field_Text Object ( [Field_MaxLength] => 50 [Field_Size] => 20 [Field_ID] => Spouse_Last_Name [Field_Name] => Spouse_Last_Name [Field_Title] => Last Name [Field_Type] => String [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [29] => Field_Text Object ( [Field_MaxLength] => 50 [Field_Size] => 20 [Field_ID] => Spouse_First_Name [Field_Name] => Spouse_First_Name [Field_Title] => First Name [Field_Type] => String [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [30] => Field_Text Object ( [Field_MaxLength] => 1 [Field_Size] => 1 [Field_ID] => Spouse_MI [Field_Name] => Spouset_MI [Field_Title] => Middle Initial [Field_Type] => String [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [31] => Field_Date Object ( [Field_Format] => INPUT [Field_MinYear] => 1900 [Field_MaxYear] => 2022 [Field_ID] => Spouse_DOB [Field_Name] => Spouse_DOB [Field_Title] => Date of Birth [Field_Type] => Date [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [32] => Field_Select Object ( [Field_Options] => Array ( [M] => Male [F] => Female ) [Field_BlankText] => Select One [Field_ID] => Spouse_Sex [Field_Name] => Spouse_Sex [Field_Title] => Sex [Field_Type] => Select [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [33] => Field_SSN Object ( [Field_ID] => Spouse_SSN [Field_Name] => Spouse_SSN [Field_Title] => SSN [Field_Type] => SSN [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [34] => Field_Select Object ( [Field_Options] => Array ( [Y] => Yes [N] => No ) [Field_BlankText] => Select One [Field_ID] => Spouse_Employeement [Field_Name] => Spouse_Employeement [Field_Title] => Is Spouse Employed? [Field_Type] => Select [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [35] => Field_Text Object ( [Field_MaxLength] => 50 [Field_Size] => 20 [Field_ID] => Spouse_Employer [Field_Name] => Spouse_Employer [Field_Title] => Employer [Field_Type] => String [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [36] => Field_Phone Object ( [Field_ID] => Spouse_Work_Phone [Field_Name] => Spouse_Work_Phone [Field_Title] => Work Phone [Field_Type] => Phone [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [37] => Field_Text Object ( [Field_MaxLength] => 5 [Field_Size] => 5 [Field_ID] => Spouse_Work_Extension [Field_Name] => Spouse_Work_Extension [Field_Title] => Extension [Field_Type] => String [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [38] => Field_Select Object ( [Field_Options] => Array ( [Y] => Yes [N] => No ) [Field_BlankText] => Select One [Field_ID] => Spouse_Coverage [Field_Name] => Spouse_Coverage [Field_Title] => Is Spouse covered under
another health plan? [Field_Type] => Select [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [39] => Field_Text Object ( [Field_MaxLength] => 50 [Field_Size] => 20 [Field_ID] => Other_Insurance [Field_Name] => Other_Insurance [Field_Title] => Insurer [Field_Type] => String [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [40] => Field_Text Object ( [Field_MaxLength] => 50 [Field_Size] => 20 [Field_ID] => Other_Insurance_Group [Field_Name] => Other_Insurance_Group [Field_Title] => Group ID [Field_Type] => String [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [41] => Field_Text Object ( [Field_MaxLength] => 50 [Field_Size] => 20 [Field_ID] => Other_Insurance_Phone [Field_Name] => Other_Insurance_Phone [Field_Title] => Phone [Field_Type] => String [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [42] => Field_Text Object ( [Field_MaxLength] => 255 [Field_Size] => 20 [Field_ID] => Other_Insurance_Notes [Field_Name] => Other_Insurance_Notes [Field_Title] => Notes [Field_Type] => String [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) [43] => Field_Select Object ( [Field_Options] => Array ( [0] => 0 [1] => 1 [2] => 2 [3] => 3 [4] => 4 [5] => 5 [6] => 6 [7] => 7 [8] => 8 [9] => 9 ) [Field_BlankText] => Select One [Field_ID] => Dependant_Count [Field_Name] => Dependant_Count [Field_Title] => Please select the number of dependents in addition to spouse [Field_Type] => Select [Field_Data] => [Field_Class] => [Field_Required] => [Field_Help] => [Field_Visible] => 1 [Field_DBField] => 1 [Field_DBType] => mysql [Field_Attributes] => [Field_Readonly] => ) ) Merchants Benefit Administration, Inc.
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New Member Enrollment

Step 1 - Please enter your Employer Group ID