Get Horizon Enrollmentchange Request Form

Filling out the Horizon Enrollment Change Request Form online is a straightforward process that allows users to efficiently update their health insurance information. This guide provides clear and detailed instructions to assist you in completing each section of the form accurately.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the group information at the top of the form. This includes the name of the group and the employer's details. Ensure all information is accurate for processing.
3. Proceed to Section A - Type of Activity. Check all relevant boxes to indicate whether you are enrolling, making changes, or terminating coverage. Be sure to provide the effective date for any changes.
4. In Section B - Employee Information, fill out all required details about yourself, including your social security number and employment details. This section is essential for the processing of your request.
5. Move to Section C - Plan Option. Select one of the plan option boxes. Only choose options offered by your employer. Indicate the plan type such as single or family.
6. In Section D - Individuals Covered, list all individuals for whom you are adding, changing, or removing coverage. Use the designated letters (A, C, or R) to indicate the type of action for each person.
7. Complete Section E - Other/Previous Insurance if applicable. This ensures any other coverage information is noted for your records.
8. For Section F - Dependent Information, answer if any dependents live at a different address and provide necessary explanations if any member’s last name is different from yours.
9. Sign and date Section G - Employee Signature to confirm that all provided information is true and accurate. Your signature is required for processing the form.
10. Finally, Section H - Employer Verification must be completed by your employer, including their signature and date to finalize the enrollment process. Ensure this section is completed to avoid delays.
11. After filling out the form, you can save changes, download a copy for your records, print it, or share it as needed.

Start filling out your Horizon Enrollment Change Request Form online today for a quick and easy submission.