Request edit access
Insurance & Benefit Request Form
EMPLOYEE BENEFITS ENROLLMENT
Email *
LUXE STUDIO SALON
130 W BELLE AVE., ST. CHARLES MI, 48655 (989) 395-8397
LUXE STUDIO SALON EMPLOYEE BENEFITS PLAN ENROLLMENT
 LUXE STUDIO & Alexis Koperna is proud to offer its employees access to Premium Prepaid & additional Permanent Benefits.

These supplemental benefits are not in competition with any group benefits through your workplace and can complement any insurance policies you may already have. If you take advantage of any insurance programs offered, your benefit program is permanent and portable throughout your lifetime.
Your First & Last Name: *
Phone Number *
Email Address *
Full Address (Street, City, State, Zip) *
What is your Birthdate? *
MM
/
DD
/
YYYY
Beneficiary's Name & Relationship *
What is the best time to reach you? *
Required
What comes next? 
Thank you for completing our request form. We will contact you shortly to set a time to meet with you and your beneficiary to setup or premium prepaid options and review additional permanent options you may be able to qualify for.  This meeting will be done via Zoom 

A copy of your responses will be emailed to .
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms