Get Ia Uniform Group N-5401 2012-2025

Filling out the IA Uniform Group N-5401 is an essential process for those seeking health coverage through their employer. This guide provides clear, step-by-step instructions to help users accurately complete the form online, ensuring that all necessary information is provided.

Follow the steps to complete the form accurately and efficiently.

1. Click the ‘Get Form’ button to obtain the IA Uniform Group N-5401 and open it in your editor.
2. Begin by filling out the Employer Data section. Provide the employer's name, group number, phone number, street address, city, state, and zip code.
3. Next, fill in the Employee Data section. Include your full name, home address, work and home phone numbers, email, birthdate, marital status, social security number, height, weight, gender, date of hire, employment status, average hours worked per week, and salary/wage.
4. In the Dependent Data section, enter the required details for dependents, including names, genders, heights, weights, birthdates, social security numbers, and whether they are full-time students.
5. Select the coverage you wish to enroll in from the Coverage Selected section. Mark the appropriate options for medical, dental, life, vision, and disability coverage.
6. Identify the reason for enrollment or change in the Reason for Enrollment/Change section. Select the appropriate option and fill in any dates required.
7. Complete the Other Coverage section if applicable, indicating Medicare coverage and any concurrent or previous coverage details.
8. In the Designated Beneficiaries section, provide names, addresses, percentages, and relationships for primary and contingent beneficiaries.
9. If you are waiving coverage, fill out the Waiver of Coverage section, stating which coverages you are declining and the reason.
10. Answer the Health Information Questions completely and accurately, using the health statement table to provide any required details for conditions listed.
11. Review the Authorization and Certification section, sign, and date where prompted.
12. After completing the form, save the changes, download the document, and print or share it as needed to finalize your submission.

Get started on your health coverage application by completing the IA Uniform Group N-5401 online today.