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Get Benefit Enrollment/change Form (adm 4717)
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How to fill out the Benefit Enrollment/Change Form (ADM 4717) online
The Benefit Enrollment/Change Form (ADM 4717) is essential for selecting or changing your coverage and updating dependent information. This guide will provide you with a clear, step-by-step approach to filling out this form online, ensuring you have all the necessary information at your fingertips.
Follow the steps to complete the online Benefit Enrollment/Change Form efficiently.
- Press the ‘Get Form’ button to access the form, which will open in the online editor.
- Begin by thoroughly completing Section I, which requires your employee information such as your employee ID number, last name, first name, address, and phone numbers.
- Move on to Section II to select the appropriate enrollment information. Indicate the event that applies to you such as 'New hire', 'Open Enrollment', or a 'Change in Status/Qualifying Event'.
- In this section, ensure you also provide the date of the event that applies to your enrollment or change.
- Next, you will detail your dependents in the designated fields. For each dependent, indicate their name, date of birth, gender, and Social Security number.
- Check the boxes for the plans you would like to add or cancel for each dependent under the 'Plan' section, ensuring you select 'Add' or 'Cancel' as appropriate.
- Once all sections are complete, review the ‘Terms and Conditions’. By signing, you certify the accuracy and completeness of the information you've provided.
- Finally, save your changes, download or print the completed form for your records, and prepare to submit it to your agency benefits coordinator.
Complete your Benefit Enrollment/Change Form online today to ensure your coverage needs are met.
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