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Unlimited PCS – Benefits Application

Benefits Application

We’ll take good care of you. Because you’ll take good care of our customers and our business. Our benefits package has you covered for health benefits and more.

Application

- Step 1 of 4

Step 1. Tell us a little bit about yourself.

Name Of Primary Applicant *

First

Last

Your Address *

Address Line 1

Address Line 2

City

State

Zip Code

Your Phone Number *

Your Email Address *

Email

Confirm Email

Step 2. Just a couple of more questions about you.

Did you file a 2019 Income Tax Return? *

Yes
No

What is Your Filing Status? *

Single
Married
Separated
Divorced
Other

Your Approximate Annual Gross Income for 2020/2021 (Include SS, Disability, Child Support, Alimony & Misc. Income) * *

Step 3. Let's talk about your dependents.

Select the number of dependents on listed on your 2020 W4 Form? *

Coverage Application: Select the number of dependents that you are applying for coverage? *

About your Dependents

Dependent Number 1

First

Last

Sex

Male
Female

Date of Birth

Legal Immigration status of dependent

US Citizen
Permanent Resident (Green Card Holder)
Naturalized Citizen
Other Visa Type
Misc. Legal Status

Dependent Number 2

First

Last

Sex

Male
Female

Date of Birth

Legal Immigration status of dependent

US Citizen
Permanent Resident (Green Card Holder)
Naturalized Citizen
Other Visa Type
Misc. Legal Status

Dependent Number 3

First

Last

Sex

Male
Female

Date of Birth

Legal Immigration status of dependent

US Citizen
Permanent Resident (Green Card Holder)
Naturalized Citizen
Other Visa Type
Misc. Legal Status

Dependent Number 4

First

Last

Sex

Male
Female

Date of Birth

Legal Immigration status of dependent

US Citizen
Permanent Resident (Green Card Holder)
Naturalized Citizen
Other Visa Type
Misc. Legal Status

Dependent Number 5

First

Last

Sex

Male
Female

Date of Birth

Legal Immigration status of dependent

US Citizen
Permanent Resident (Green Card Holder)
Naturalized Citizen
Other Visa Type
Misc. Legal Status

Dependent Number 6

First

Last

Sex

Male
Female

Date of Birth

Legal Immigration status of dependent

US Citizen
Permanent Resident (Green Card Holder)
Naturalized Citizen
Other Visa Type
Misc. Legal Status

Disclaimer *

I have read and understand disclaimer

Unlimited PCS does not provide company-sponsored health insurance or other insurance coverage at this time. Unlimited PCS has however adopted a health insurance reimbursement plan that provides reimbursement of up to a specified amount per month to employees who have their own individual health insurance coverage and who provide proof of coverage and proof of their monthly premium payments. Please refer to the Company Employee Handbook for further details.

Electronic Signature

Clear Signature

Need Assistance?

Please email us benefits@unlimitedpcs.com with your Full Name, Contact Phone number and someone will reach out to you in a timely manner.

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