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Hi {MemberFirstName}, just a few more details.

All fields required unless marked optional

SEIU Insurance

Please select coverage

Wish to change the product? Visit seiumb.com

Within the last 24 months, have you used tobacco or nicotine in any form?

Yes
No

A valid answer must be supplied.

Would you like to add family members to your coverage? (Optional)

Spouse/Domestic Partner

Dependent Children

Children must be 26 years or younger.

Children must be 25 years or younger.

By continuing, I acknowledge that I am actively at work and am currently a member of SEIU and that I must continue such membership to keep this insurance in force.

Spouse/Domestic Partner (DP) Information

All Fields Required

First Name

Enter your spouse's first name

MI (Optional)

Last Name

Enter your spouse's last name

Date of Birth

Date of birth is required

Within the last 24 months, has {SpouseFirstName} used tobacco or nicotine in any form?

¿{SpouseFirstName} ha usado productos de tabaco o nicotina durante los últimos 24 meses?

Yes
No

A valid answer must be supplied.

Sex Assigned at Birth

Male
Female

Please select a gender

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{SpouseFirstName} exceeds the age requirements to enroll for coverage.

Update your family selection above to continue. Contact SEIU Member Benefits for additional help at 1-866-751-0260

Sorry! Your age exceeds the plan requirements to enroll for coverage.

Contact SEIU Member Benefits for additional help at 1-866-751-0260

Sorry! Due to your state of residence, this product is currently not available.

Please contact us today at 1-866-751-02601-800-751-0260

Sorry! Your age exceeds the plan requirements to enroll for coverage.

Contact SEIU Member Benefits for additional help at 1-866-751-0260

{SpouseFirstName} exceeds the age requirements to enroll for coverage.

Update your family selection above to continue. Contact SEIU Member Benefits for additional help at 1-866-751-0260

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