Get Excellus Simply Blue Group Enrollment Form

Completing the Excellus Simply Blue Group Enrollment Form online is a straightforward process that involves several key sections. This guide provides detailed instructions on how to accurately fill out each part of the form to ensure successful enrollment.

Follow the steps to effectively complete the form.

1. Press the ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by filling out the Group Employer Information. This section requires your Group Benefits Administrator to provide necessary group details, such as Subscriber Status, Group Number, and Employer Name. Ensure that this information is complete and printed clearly in blue or black ink.
3. In the Subscriber Plan section, input the Employee Number and select the applicable plan by checking the corresponding box for copay options, deductible options, and coverage types. Make sure to select one option from each category that meets your needs.
4. Indicate the reason for enrollment or change in the Reason for Enrollment/Change section. Choose the relevant reason such as New Hire, COBRA, or Add Dependent, and provide any required additional information.
5. Fill out the Subscriber Information section with essential personal details, including Last Name, First Name, Date of Birth, Contact Information, and Social Security Number. Ensure all fields are accurately completed.
6. In the Other Coverage Information section, indicate whether you or any dependent have had other coverage in the last 63 days, and provide details if applicable.
7. Complete the Cancellation Information if applicable, specifying who is being canceled and the reason for cancellation.
8. Provide Dependent Information by listing all individuals to be covered, including relationship details and necessary identification information.
9. Confirm all information is correctly filled out and sign the form in the Release/Signature section. Note that a subscriber signature is required for processing.
10. Once all sections are completed, you can save your changes, download the filled form, print it, or share it as needed.

Start filling out your enrollment form online to ensure a smooth application process.