Get 1199 Online Application

Completing the 1199 Online Application for Young Adult coverage is a crucial step in securing benefits for your dependent children. This guide will help you navigate the process with clear instructions and support.

Follow the steps to successfully complete the application online.

1. Press the ‘Get Form’ button to access the 1199 Online Application and open it in your preferred digital format.
2. Begin filling out the member's information section. Enter the member’s full name, member ID, date of birth, sex, address, city, state, zip code, home telephone, cell phone number, and email address.
3. Proceed to the young adult’s information section. Input the dependent’s full name, social security number, date of birth, sex, and address (if different from the member). Include the city, state, zip code, home telephone, cell phone number, and email address.
4. Next, answer the question regarding the dependent’s other parent. Indicate whether they have access to other health insurance and provide the other parent's full name and date of birth if applicable.
5. If applicable, provide the other parent's employer information, including the employer's full name, address, city, state, zip code, and telephone number.
6. Select the type of coverage by checking all that apply: medical, hospital, prescription, dental, or vision.
7. Enter the effective date of coverage, name of the insurance plan, policy/group number, and insurance plan telephone number.
8. Review the authorization and signature section. Ensure that both the dependent and the member sign and date the form to validate the application.
9. Once all fields are completed and accurate, save your changes. You can also download, print, or share the form as required.

Start completing your documents online today to ensure timely benefits for your dependent.