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Please follow the 3 easy steps below.

Please use a black ink pen when completing the forms.

• Complete the Enrollment Form:
  • Click here to download and print the HMO Enrollment Form.
  • Complete the "Employee Information" section.
  • Complete the "Dependant Information" section (if needed).
  • Sign and date where indicated.
  • Do not forget to select a dentist.
• Complete the Payroll Deduction Authorization Form:
  • Click here to download and print the payroll deduction authorization form.
  • Complete the "Employee Information" section.
  • Enter the exact amount of premium for your plan:
    • $12 for employee only.
    • $20 for employee and one (1) dependent.
    • $28 for employee and two (2) or more dependents.
  • Sign and date where indicated.
• Send Back the Completed Forms:

  Send the 2 forms: enrollment and payroll deduction authorization either by:

  • Fax:
    (619) 325-0473
  • Mail:
    FEA Service Center
    P.O. Box 927389
    San Diego, CA 92192-7389

If you process the allotment yourself via the automated system (PostalEase), please make sure to indicate that it is a savings account, the routing number is 041000124, account #4441xxxxxxxxx (9 digits of your SSN).

Please remember to send us a copy of the allotment form.

Do not hesitate to contact us if you have any question. We'll be happy to help you process your allotment.