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Enrollment Form

To apply, please select the appropriate coverage needed and click "Send Me The Forms." You will receive an email with the forms needed to apply. Fill out the forms as instructed in the email. If you experience any problems or have questions regarding specific coverage options you may also call Toll Free 1-888-400-9303.

** IMPORTANT: Form items marked in BLUE TEXT are required fields.
*** Not all State agencies are eligible for this program and the rates listed. Members of the LSU System, other State Universities, Community Colleges and Public School Systems have their own payroll systems and are not included. Please contact Starmount or your Human Resources Representative with any questions.
Insurance Type:
Select:            If you are currently enrolled in Starmount ’s Dental Plan, you only need to elect vision coverage.
Select Vision Plan:                If you you have chosen to enroll in a Vision plan, please choose which type.
Coverage Level:
Have you been hired within the last 30 days?:
Email Address:
ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.