Get Section 1 - Health Information - For Life/ad&d ... - Page One Intranet

Filling out the Section 1 - Health Information form is essential for ensuring that you receive the appropriate benefits. This guide will provide clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to accurately complete the form online.

1. Press the ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin with the group customer information section. Enter the name of your group customer/employer, the group customer number, division, and class. Ensure the date of hire and coverage effective date are filled out correctly.
3. Move to the enrollment information section. Complete your name, social security number, and address. Indicate whether you are an employee or retiree, your marital status, and your date of birth. Include your job title and specify if this is a new enrollment or a change in enrollment.
4. Indicate your gender and the number of hours worked per week. If applicable, provide the qualifying event date for COBRA continuation.
5. Review the dental insurance options and select your desired level of coverage. Options include employee only, employee plus spouse/domestic partner, employee plus child(ren), or family coverage.
6. If you are applying for coverage for your spouse/domestic partner or children, provide their names and dates of birth in the designated sections. If you need additional lines, check the box and provide the extra information on a separate piece of paper.
7. Read the fraud warnings carefully before signing. Make sure you understand the implications of providing false information.
8. In the declarations and signature section, affirm that all information provided is true and complete. Sign and print your name, along with the date of signing.
9. After completion, ensure to save changes, download, print, or share your form as needed.

Complete your form online today to ensure you receive the benefits you are eligible for.