Get Form Ha 0891 1012

Completing the Form Ha 0891 1012 online is an important step in securing health benefits as a state employee. This guide provides step-by-step instructions to help you successfully fill out each section of the form, ensuring that your application is complete and accurate.

Follow the steps to successfully complete the form online.

1. Click the ‘Get Form’ button to obtain the form and open it for online completion.
2. Fill in your employee information in Section 1. Provide your full name, social security number, date of birth, gender, and address. Ensure all details are accurate and clearly printed or typed.
3. In Section 2, select your desired medical coverage. Check the appropriate box for the plan you wish to enroll in or select to waive coverage if you do not wish to participate.
4. Move to Section 3 to indicate your choice regarding prescription drug coverage. Just like in Section 2, select whether you want to enroll or waive this coverage.
5. Complete Section 4 by listing your eligible dependents. Include their names, dates of birth, genders, and social security numbers as required, and ensure that supporting documentation is attached if necessary.
6. If applicable, complete Section 5 to indicate any changes to existing coverage, such as adding or deleting a dependent.
7. In Section 6, read the employee certification statement carefully, then sign and date the application to confirm that all information is correct.
8. Finally, review your form for any missing information or errors before saving your changes. You can then download, print, or share the completed form as needed.

Get started on completing your Form Ha 0891 1012 online today to ensure your health benefits are processed promptly.