Follow the steps to complete the online application efficiently.

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. Select your enrollment type by checking one of the options: New enrollment, re-hire, or add a family member to existing coverage. This helps determine your application process.
3. Enter the group number and plan type as specified by your employer. These details are crucial for associating your application with the correct coverage plan.
4. Indicate the effective date for your requested coverage. Ensure that this date aligns with your intended start of benefits.
5. Provide your Social Security number, group name, and personal details including your first name, middle initial, last name, date of hire, and date of birth.
6. Choose your dental plan by checking either the Dental PPO or Dental HMO option. Note that if you select the Dental HMO, you will need to choose a dental provider from the Blue Shield Dental Provider Directory.
7. Indicate your marital status by selecting yes or no for a domestic partner. This information is necessary for coverage considerations.
8. Fill in your business and home phone numbers, and your email address to ensure proper communication.
9. Complete your residential address information, including city, state, and ZIP code.
10. List all family members you wish to cover, including their relationship to you, first names, middle initials, last names, dates of birth, and Social Security numbers. Ensure that dependent children are 18 years or older to include them.
11. If applicable, certify any dependents over 18 and enrolled as full-time students, providing their school information and hours per week.
12. Review and read the disclosure statements thoroughly. Confirm your understanding and authorize any necessary disclosures by signing the application.
13. Final review: Ensure all information is correct and complete. Save changes, if prompted, and download, print, or share the form as needed.

Complete your form online today for seamless processing and coverage!