Get Benefit Application & Change Form County Of Imperial - Co Imperial Ca

This guide provides clear instructions on how to complete the Benefit Application & Change Form for the County of Imperial online. Whether you are applying for new coverage or making changes to your existing benefits, this step-by-step guide will make the process straightforward and accessible.

Follow the steps to complete your Benefit Application & Change Form online.

1. Press the ‘Get Form’ button to retrieve the form and open it in your preferred editing tool.
2. Begin by entering your employee information. Ensure you complete the fields for Social Security Number, Last Name, First Name, Middle Initial, Current Mailing Address, Home Phone, Department, Position Title, Hire Date, Date of Birth, and Personal Email Address. Use clear and legible text.
3. Indicate your health coverage election by marking the appropriate box. If you wish to waive coverage, ensure to complete the Refusal of Personal Coverage Form.
4. Move to Section A and check the appropriate qualifying event, which may include marriage, newborn, or loss of previous coverage.
5. In Section C, select your Family Category and indicate your desired Medical Plan Level. Choose from options like Employee Only, Employee + Spouse/Domestic Partner, Employee + Child(ren), or Employee + Family.
6. Complete Section E for Spouse and Dependent Information. Provide necessary details for each dependent and indicate if any should be added or deleted from coverage.
7. Fill in the Reimbursement Account information in the Medical & Dependent Flex 125 section, specifying the amounts you wish to contribute for health care and dependent care reimbursement.
8. Designate your basic life insurance beneficiaries, including full names, addresses, relationships, and percentage of benefit.
9. Read and agree to the authorization statement at the bottom of the form. By signing, you certify that the information provided is accurate and authorize the necessary disclosures for processing your application.
10. Finally, review the entire form for accuracy. You can save your changes, download a copy for your records, print it out, or share it as required.

Complete your Benefit Application & Change Form online today to ensure your coverage needs are met.