• I have been offered the following benefits by my employer and would like to enroll in coverage for:

    Mi empleador me ha ofrecido los siguientes beneficios y me gustaría inscribirme en la cobertura para:


  • I understand that I must contact Sandi at The Otium Agency Inc. (657) 284-5222 by Wednesday, February 22nd, 2017 to inform them of my decision to enroll.

    Entiendo que debo contactar a Sandi en The Otium Agency Inc. (657) 284-5222 antes de el miércoles 22 de febrero de 2017 para informarles de mi decisión de inscribirme.

  • Date Format: MM slash DD slash YYYY

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