Enrollment

There is no enrollment at this link. Please verify the web page link and try again.

You cannot enroll outside the enrollment period.

Enrollment Start Date:	{{EnrollmentStartDate}}
Enrollment End Date:	{{EnrollmentEndDate}}

{{GroupName}} {{FormDivisionTitle}} Enrollment Form

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${{type.Cost.toFixed(2)}} {{type.Frequency}}

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Primary

First Name*

Middle Name

Last Name*

Date of Birth*

Employee Number

Note: Your employee number should be a unique, constant and repeatable identifier. This can be your payroll ID, employee ID, badge number, Tax ID, etc. If you do not know your employee number, please reach out to your HR department.

Rank or Member

Correctional Institution

Name of banking institution

Routing number

Account number

Date of first transaction

Date of second transaction

MOCOA Dues $10.00 MASA Membership $7.00 Administration fee $1.00 Total per pay $18.00

Spouse

First Name*

Middle Name

Last Name*

Date of Birth

Remove Spouse

Dependents

First Name*

Middle Name

Last Name*

Date of Birth

Note: All dependents must be under the age of 26 unless primary member resides in the state of Wyoming

Physical Address

Country*

State*

City*

Zip*

Address*

Check here if mailing address is the same as the physical address

Mailing Address(Not required if checkbox above is checked)

Country*

State

City

Zip

Address

Phone*

Alt. Phone

Email*

Health Plan Coverage

I will be enrolled in an HSA-eligible health plan on my plan effective date.

I will not be enrolled in an HSA-eligible health plan on my plan effective date.

I acknowledge that by clicking above I have elected to enroll into {{FormDivisionTitle}}’s plan program. I hereby authorize my employer to deduct from my paycheck(s) an amount equivalent to the selected amount for the corresponding {{FormDivisionTitle}} plan. I further acknowledge, that should my employment with my employer be terminated, whether voluntarily or involuntarily, my employer will have the right to deduct from my final paycheck any and all amounts paid upfront by my employer for my {{FormDivisionTitle}} plan that have yet to be deducted from my paycheck(s).

I acknowledge that I have been offered the opportunity to enroll in the {{FormDivisionTitle}} plan program via a payroll deduction and have decided to opt out. Additionally, I understand the potential out of pocket exposure resulting from an emergent air or ground transport and willingly assume the responsibility of such balance bill.

I authorize Piedmont Payment Services, LLC (PIEDMONT) to perform electronic funds transfer (EFT) debits on a semi-monthly basis from the account shown above, and I authorize my bank to debit the account shown above. I understand that the funds, less the service fee, will be used to pay the BILLER(S) listed above. I also understand that my accounts with the BILLER(S) may be cancelled if any EFT attempt is returned/declined resulting in insufficient funds to pay my invoiced amounts in full. If any EFT debit is returned/declined by my financial institution as unpaid (non-sufficient funds or uncollected funds), I authorize Piedmont to suspend future attempts, and I understand that I will be responsible for future payments to the BILLER(S).

This authorization is to remain in force until PIEDMONT has received notification of its termination. Any termination notice should be sent to PIEDMONT by mail to: PO Box 940, Fortson, Georgia 31808 or by e-mail with reply requested to: support@piedmontpays.com. By signing this document, I acknowledge that I have read and agree with the Processing Terms and Conditions. If not attached here, a complete copy may be found at http://www.piedmontterms.com

I affirm that I have Major Medical Health Insurance through Insurance Company with Plan #. My medical coverage is currently in force, covers emergency transportation situations, and does not contain unreasonable limitations on repayment to providers for emergency transportations. I affirm that the aforementioned coverage will continue to be maintained so long as I am a MASA member, and that the failure to maintain such coverage may render my MASA plan null and void.

Name

Print PDF

Primary

{{ Primary.FirstName }} {{Primary.MiddleName}} {{Primary.LastName}} - Birth Date: {{Primary.DateOfBirth}} - Employee Number: {{EmployeeId}}
{{MemberRank}} {{CorrectionalInstitution}} {{BankingInstitutionName}} {{RoutingNumber}} {{AccountNumber}}
{{FirstTransactionDate}} {{SecondTransactionDate}}

Spouse

No spouse added

{{Spouse.FirstName}} {{Spouse.MiddleName}} {{Spouse.LastName}} - Birth Date: {{(Spouse.DateOfBirth == null || Spouse.DateOfBirth == "") ? "N/A" : Spouse.DateOfBirth}}

Dependents

No dependents added

{{dep.FirstName}} {{dep.MiddleName}} {{dep.LastName}} - Birth Date: {{(dep.DateOfBirth == null || dep.DateOfBirth == "") ? "N/A" : dep.DateOfBirth}}

Physical Address

{{PhysicalAddress.Line1}} {{PhysicalAddress.City}}, {{PhysicalAddress.State}} {{PhysicalAddress.Zip}} {{PhysicalAddress.Country}}

Mailling Address

{{PhysicalAddress.Line1}} {{PhysicalAddress.City}}, {{PhysicalAddress.State}} {{PhysicalAddress.Zip}} {{PhysicalAddress.Country}}

{{MailingAddress.Line1}} {{MailingAddress.City}}, {{MailingAddress.State}} {{MailingAddress.Zip}} {{PhysicalAddress.Country}}

There is no enrollment at this link. Please verify the web page link and try again.

You cannot enroll outside the enrollment period.

{{GroupName}} {{FormDivisionTitle}} Enrollment Form

Please confirm

Primary

Spouse

Dependents

Physical Address

Mailling Address

Phone

Alt. Phone

Email

Product

Insurance

Enrolled!

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