Follow the steps to complete your employee application.

1. Press the ‘Get Form’ button to obtain the application document and open it in an editable format.
2. Identify the reason for your application by checking the appropriate box, such as new group enrollment, new hire, or open enrollment. Ensure that the date is filled in if applicable.
3. In Section 1, select or write the names of the medical benefit plans you wish to enroll in. Make sure to check all applicable options, including dental and vision plans.
4. Complete Section 2 by providing your personal information, including your name, Social Security number, employment status, and contact details. Remember to use clear and legible writing.
5. In Section 3, fill out information for any dependents you are enrolling. Include names, Social Security numbers, and select their corresponding coverage preferences.
6. For Sections 4 and 5, if applicable, provide information regarding any existing health insurance coverage and Medicare enrollment. Include necessary details like coverage type and policy numbers.
7. In Section 6, list the life insurance beneficiary along with their relationship to you, ensuring to include their address details.
8. Complete Section 7 by acknowledging the privacy policies regarding your personal information. Review this section closely.
9. Sign Section 8 to authorize the accuracy of the information provided and indicate your agreement to the coverage terms. Include the date and print your name.
10. Ensure that all pages are returned, as your signature on the last page is essential for processing. Once completed, save your application, or print and share it as needed.

Take action today and complete your C12914-PR-FF-REV2_9-12 Employee Application online for a smooth enrollment experience.