Trellis Employer Enrollment

Personal Information

First Name *

Last Name *

Preferred Name *

Date of Birth *

Contact Information

Work Email * Please use the work email address associated with the employee to verify eligibility.

Phone *

Preferred Email

Address

Address *

City *

State *

Zip Code *

Employer

Sponsor (employer) *

Enrollee *

Demographics

Gender Identity *

Sex at Birth *

Preferred Method of Contact *

Additional Info

How did you hear about Trellis?

Additional Notes