Follow the steps to effectively fill out the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Start by entering the requested effective date at the top of the form. This indicates when you would like coverage to begin.
3. Proceed to Section 1, where you will input employer and employee information. Provide the group name, group/account number, your Social Security number, last name, first name, mailing address, city, state, phone number, and email address.
4. In Section 1, you will also select your Plan Options such as J Plan, EPO (PCP), and BlueCare (HMO), then indicate your Primary Care Physician’s name or NPI number.
5. Indicate your marital status by checking the appropriate box: single, widowed, married, or domestic partner.
6. Next, fill out your employment status and date of birth (DOB) along with selecting your gender.
7. In Section 2, mark the appropriate reason for new enrollment under 'New Enrollment' and check the box that fits your situation (e.g., new group, open enrollment, new hire). If applicable, indicate if you are refusing coverage.
8. In Section 3, if you need to make any changes or cancellations, specify the effective date and the reason for change or cancellation (e.g., marriage, divorce, address change). Remember to provide your signature if you are voluntarily canceling.
9. In Section 4, list all dependents that need to be added or removed by filling in their information (last name, first name, SSN, DOB) and marking 'Add' or 'Remove'.
10. Complete Section 5 by indicating whether you or any dependents will have coverage by Medicare after obtaining health insurance.
11. Finally, review Section 6 for the subscriber signature. Read the certification statement, sign, and date the form.
12. Once all sections are filled, you can save changes, download, print, or share the completed form.

Submit your completed documents online to ensure prompt processing.