Enrollment Portal | Chroma Early Learning Benefits

Step 1 of 4

Employee Information

First name *

Last name *

Date of birth *

Gender

Work or Personal Email *

Mobile Phone *

Residential ZIP Code *

Assigned Campus Location *

I am currently enrolled in Medicare, Medicaid, PeachCare, or TRICARE.

Step 2 of 4

Select Your Plan Option

Choose one of the options below. Chroma's master plan includes 100% ACA preventive care, in-person PCP doctor visits, specialist copays, urgent care, diagnostic labs/X-rays, 24/7 MDLive telemedicine, behavioral health counseling, Cigna prescription coverage, and $50,000 of group term life insurance.

⭐ Chroma Master Plan: MEC Plus Advantage $118.75/mo EEFull clinical care, $20 doctor, $50 specialist/urgent/labs, $200 imaging + $50k life 🚫 Decline Coverage (Waiver)I am covered elsewhere or decline participation

👈 Select a plan option to view covered clinical services and rates.

Reason for Declining Coverage *

Name of Current Insurance Carrier (Optional)

Step 3 of 4

$50,000 Life Insurance Beneficiary Designation

Coverage Election: Employee Only

Your MEC Plus Advantage plan and $50,000 group term life insurance policy provide individual employee coverage at $118.75/month pre-tax (~$54.81 bi-weekly).

Primary Beneficiary Designation

Designate the primary beneficiary who will receive the $50,000 tax-free lump-sum benefit in the event of your death.

Beneficiary Full Legal Name *

Relationship to Employee *

Beneficiary Contact Phone

Beneficiary Email Address

You have elected to waive coverage for the 2026–2027 plan year. Click Next to review and electronically sign your waiver acknowledgment.

Step 4 of 4

Review Elections & Electronic Signature

I hereby authorize Chroma Early Learning Academy LLC to deduct my required pre-tax salary reduction contributions for the elected plan tier from my regular payroll compensation under the Chroma Section 125 Cafeteria Plan. I understand that my elections are binding and generally irrevocable for the 2026–2027 plan year, except in the event of an IRS-recognized qualifying life event submitted within 30 days.

I certify that I have been offered the opportunity to enroll in Chroma's group health and life benefits program, and I affirmatively elect to decline coverage for the 2026–2027 plan year. I understand that I may not enroll until the next annual open enrollment period unless I experience a qualifying life event and provide formal notification within 30 days.

Type Full Legal Name for Electronic Signature (ESIGN Act Compliant) *

By typing your legal name, you execute an electronic signature binding under the Federal ESIGN Act and state UETA laws. Timestamp:

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Submission Confirmed

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