Follow the steps to complete your application accurately.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Fill out Section A: Subscriber Information. This includes providing your name, contract number, birth date, marital status, sex, residence address, and telephone numbers. Ensure all fields are accurately documented.
3. Move to Section B: Dependent Information. Here, you must provide information about your incapacitated dependent, including their first and last name, relationship to you, social security number, sex, birth date, date condition developed, and diagnosis. Accuracy is critical in this section.
4. Complete Section C: Medicare Information. Indicate whether your dependent is entitled to Medicare due to their condition by selecting 'Yes' or 'No'.
5. In Section D: Other Insurance, disclose if your dependent has other health insurance coverage. If applicable, provide information such as the name of the insured, insurance company details, policy number, contract type, and policy effective date.
6. Fill out Section E: Additional Information. This section might require further details relevant to your application.
7. Proceed to Section F: Verification. Here, you certify that your dependent meets the criteria for incapacitation and that the information provided is accurate. You must also provide your signature and the date signed.
8. Next, Section G: Dependent’s Attending Physician Certification must be completed by the physician. It requires their insights concerning your dependent's condition, examination dates, treatment plans, and other relevant details.
9. Finally, save the completed application. Ensure to download, print, and keep a copy for your records before mailing it to the address provided. You can also share the form if needed.

Complete your application online to ensure timely processing of your disabled dependent's coverage.