TRES APPLICATION

TRES Core $0 RBP Plan

Confidential Employee Enrollment Application
Enrollee Information

(All information must be completed to ensure coverage)
Need more information?

Click here: Tres Medical Plan

Call or text: 213-908-1098

Email: benefits@healthyavenew.com
Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Social Security Number (confidential)*
123-45-6789
Gender*

MaleFemale
Marital Status*
Date of Hire

MonthDayYear
Date
Employer*
Employment Status*

Full TimePart Time
Height*
Weight*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Coverage & Change Request Information

You may be required to provide proof of the event.
Effective Date (Jan. 1, 2026)

MonthDayYear
Date
Insurance Requested (new enrollment):

New EnrollmentStatus Change
For status change, please describe here:
Coverage Level*
If changing plans, indicate Qualifying Event:
If Qualifying Event is "Other," please specify:
Date of Qualifying Event

MonthDayYear
Date
Are you currently actively at work and able to perform the duties of your occupation?*

YesNo
How many hours are you regularly working per week with your current employer?
Estimated hours per week
Please scroll to bottom to sign if you are not requesting dependent coverage.
Family Information

Only for those applying for coverage today - all information required
Spouse

First NameLast Name
Social Security Number
123-45-6789
Gender
Height
Weight
Date of Birth

MonthDayYear
Date
Child #1

First NameLast Name
Social Security Number
123-45-6789
Gender
Height
Weight
Date of Birth

MonthDayYear
Date
Child #2

First NameLast Name
Social Security Number
123-45-6789
Gender
Height
Weight
Date of Birth

MonthDayYear
Date
Child #3

First NameLast Name
Social Security Number
123-45-6789
Gender
Height
Weight
Date of Birth

MonthDayYear
Date
Child #4

First NameLast Name
Social Security Number
123-45-6789
Gender
Height
Weight
Date of Birth

MonthDayYear
Date
Since the TRES Plan you’re signing up for may carry a high out-of-pocket maximum under certain medical situations, would you be interested in adding optional supplemental coverage for just $6.92/week, giving you extra protection against high out-of-pocket costs like hospital stays, emergency services, and unexpected medical bills? (Note: This is an expression of interest, not a commitment.)*

YesNoMaybe
Employee Agreement (signature required)
I authorize my employer to deduct the necessary contributions toward the benefits I have selected on a pre-tax basis from my pay. I understand that I cannot change the benefits I have selected or revoke this pay deduction authorization before the beginning of the next plan year unless that change or revocation is made on account of, and corresponds with, a change in status, a special enrollment event, or any other event that permits a mid-year change or revocation of elections under the terms of my employer’s Section 125 cafeteria plan
Employee Signature*

Clear
Date*

MonthDayYear
Date
If signed by a representative of enrollee, please indicate the representative’s authority to act on behalf of enrollee:
Should be Empty:

TRES Core $0 RBP Plan

Enrollee Information

Coverage & Change Request Information

Family Information

Employee Agreement (signature required)