Get Enrollment Change Form

Completing the Enrollment Change Form online is an essential step for users seeking to make updates to their health insurance coverage. This guide provides you with clear, step-by-step instructions to ensure a smooth completion of the form.

Follow the steps to fill out the Enrollment Change Form accurately.

1. Click the ‘Get Form’ button to access the Enrollment Change Form and open it in your preferred editor.
2. Identify the purpose of the enrollment request. Check the appropriate box for 'New Hire', 'Rehire/Reinstatement', 'New Group Enrollment', 'Late Enrollment', or 'Other'.
3. Enter the effective date and the date of hire in the designated fields to provide context for the enrollment change.
4. Complete Section A for coverage selections. Print clearly in black ink and choose the medical, dental, and life insurance options that apply to you.
5. In Section B, input your personal information including your social security number, name, job title, home address, and contact details.
6. Fill out Section C with the details of individuals you are enrolling or changing coverage for—this includes their names, relationships, and relevant medical information.
7. If you are waiving any coverage, proceed to Section F and clearly indicate which coverages are being declined, along with the reasons.
8. Review all entries for accuracy. Ensure all required fields are completed before proceeding.
9. Once you have filled out the form completely, you can save your changes, download a copy for your records, print the form, or share it as necessary.

Complete your Enrollment Change Form online today to ensure your health insurance needs are met.