top of page
Agri Supply Logo.png

Complete this form to enroll in or change your voluntary benefits for this upcoming year.

For Open Enrollment Only 

Effective June 1, 2024

Benefit Options

Enroll in Allstate Accident Policy?
Who would you like to enroll in Allstate's Accident Policy?
Which Allstate Accident Policy?
Enroll in Allstate Cancer Policy?
Who would you like to enroll in Allstate's Cancer Policy?
Which Allstate Cancer Policy?
Who would you like to enroll in Allstate Universal Life Coverage?
Child 1 Gender
Child 2 Gender
Child 3 Gender
Child 4 Gender
Enroll in Short Term Disability Policy?
Employee Gender
Spouse/Domestic Partne Gender
Child 1 Gender
Child 2 Gender
Child 3 Gender
Child 4 Gender

Thanks for submitting! If we have any additional questions, we will contact you directly! You'll receive a copy of your responses within the next week.

bottom of page