Health Insurance Form – London Auto Truck Center

Health Insurance Interest Form

**All fields are required**

Full name

Are you a full-time employee working 30+ hours each week?

Yes

Gender

Male

Female

Date of Birth

Coverage Type

Employee Only

Employee & Spouse Only

Employee & Child(ren) Only

Full Family Coverage

Home Zip Code

Thank you for your interest. Health insurance is only available to full-time employees at this time.