Get 2014 Enrollment/waiver Form - Usi Affinity

This guide provides comprehensive, step-by-step instructions for users on how to accurately fill out the 2014 Enrollment/Waiver Form - USI Affinity online. Whether enrolling for coverage or waiving it, following these instructions will help ensure all necessary information is correctly submitted.

Follow the steps to complete the Enrollment/Waiver Form effectively.

1. Click ‘Get Form’ button to access the 2014 Enrollment/Waiver Form and launch it in your preferred document editing tool.
2. Begin with Section I, Applicant Information. Fill out your effective date, employer name, last name, first name, middle initial, payroll location, and social security number. Ensure all information is accurate.
3. Complete your address details, including city, state, zip, and county. Choose your enrollment status from the provided options: Active Employee, Rehired Employee, COBRA/mini-COBRA, or Act 4 Dependent.
4. Provide your home or cell phone number and enter the date of your full-time hire or rehire. Specify your marital status by checking the appropriate box.
5. If applicable, fill out the COBRA/mini-COBRA reason section. This includes selecting reasons like Deceased, Involuntary Lay-Off, or Left Employment, as well as the start and end dates and the date of the event.
6. Proceed to Section II, Enrollment Information and Coverage Selection. Indicate your sex, date of birth, and dependent status if over age 26. Select your desired product options for medical, vision, and dental.
7. If you used tobacco regularly in the last six months, respond to the tobacco usage questions accurately.
8. Continue to provide information for each dependent in the respective sections, including their first name, middle initial, last name, social security number, sex, relationship to you, date of birth, and any applicable tobacco usage details.
9. If waiving coverage, complete Section III. Indicate whether you are declining medical, vision, or dental coverage for yourself and/or your family members by checking the appropriate boxes and providing a reason for declining coverage.
10. Move to Section IV to report any other group or non-group health insurance coverage, including the name of the insurance carrier, policy number, and policyholder details.
11. Finally, complete Section V by signing and dating the form. Ensure your signature is only included if you are waiving coverage. This section reiterates your understanding of the enrollment and privacy practices.
12. Review all completed sections for accuracy, save your changes, and proceed to download or print the form for submission.

Complete your enrollment or waiver process online today.