Get Benefit Design Group Enrollment Form

Completing the Benefit Design Group Enrollment Form online is a straightforward process. This guide will help you navigate through each section of the form to ensure that you provide all necessary information accurately.

Follow the steps to complete your enrollment form effectively.

1. Click ‘Get Form’ button to acquire the form and open it in your preferred editor.
2. Indicate your enrollment status by selecting from the options provided: New enrollee, Coverage change, Add/Delete dependents, Termination, COBRA, Direct Bill COBRA, or Waiver. Enter your employer’s name, customer number, phone number, and the requested effective date.
3. Fill in your personal information, including your full name, Social Security number, address, sex, birth date, and contact number. Make sure to provide your full-time hire date and the number of hours you work per week. Confirm if you are actively at work on a full-time basis.
4. Select your marital status by marking Single or Married. If you're applying for Life/AD&D, STD, or LTD coverage, provide your occupation, class, and annual salary details. Designate a beneficiary and their relationship to you.
5. If needed, list your primary care physician or medical center name, along with their identification number. Indicate whether you are an existing patient, disabled, or a student. Include information for dependents as necessary.
6. If applicable, enter the participating dentist/provider code and details regarding Medicare and TEFRA eligibility.
7. Complete your benefit elections by selecting your desired medical, dental, and vision plans. Ensure to indicate if you have used tobacco products within the last two years.
8. Provide information regarding any other insurance coverage you or your dependents may have. Fill in the name of the other health insurer and policy number, along with the effective and termination dates.
9. In the certification section, confirm your understanding of the terms. Sign and date the form where indicated, as well as the employer’s signature/verification if required.
10. Finally, save all changes made, then download, print, or share the form as necessary.

Complete your Benefit Design Group Enrollment Form online today to ensure you receive the coverage you need.