Get Application For Enrollment/change (for Groups 1-50). Enrollment Application

Filling out the Application For Enrollment/Change is essential for users seeking new enrollment or changes to their health coverage. This guide provides clear, step-by-step instructions to help you complete the application accurately and efficiently.

Follow the steps to successfully complete the application.

1. Press the ‘Get Form’ button to access the form and open it in the editor.
2. Fill in your group number, subgroup, and class in the designated fields. Ensure that all information is accurate, as incomplete entries may delay coverage.
3. Provide the group name and the employee's last name. Then enter the full-time date of hire and original date of hire in the specified format (mm/dd/yyyy).
4. Enter the employee's mailing address, including city, state, and ZIP code, along with the daytime phone number and email address.
5. Indicate marital status by selecting from the available options, and complete the eligibility waiting period start date and hours per week.
6. Fill in the requested effective date of coverage (mm/dd/yyyy) and provide the primary language spoken.
7. For new enrollment or changes, select the relevant options regarding the type of enrollment, termination, or event causing the change. Provide the date of these events as well.
8. List all members for whom you are adding, changing, or terminating coverage, including their relation to the employee, date of birth, and gender.
9. Select the plan preferences for dental and medical coverage, ensuring that any selections align with the options provided by your group administrator.
10. If applicable, complete the COBRA or non-COBRA continuation enrollment section, indicating the type of continuation and reason for entitlement.
11. Sign and date the application to confirm all information is correct and complete. The application must be signed or it will be returned.
12. Once completed, save changes, download, or print the form as needed, and submit according to your group administrator's instructions, either by mail or fax.

Start completing your Application For Enrollment/Change online today to ensure seamless coverage!