Get Enrollment Form For Group Insurance - Instantbenefits.net

Filling out the Enrollment Form for Group Insurance is an important step in securing the benefits you need. This guide provides step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete your enrollment form smoothly.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Begin with the 'Group Customer Information' section. Here, enter the name of the group customer or employer, the group customer number, division, class, department code, date of hire, and the coverage effective date. If you are applying for COBRA, include the original COBRA effective date and termination date as applicable.
3. In the 'Your Enrollment Information' section, complete your personal details using blue or black ink. Enter your full name, social security number, address, and select your employment status as either employee or retiree. Also, provide your date of birth, job title, and specify if this is a new enrollment or a change in enrollment.
4. Indicate your marital status and basic annual earnings in the specified sections. If this enrollment is due to a qualifying event, provide the date it occurred.
5. In the benefits section, review your options for disability income insurance, dental insurance, and any applicable benefits. Select the coverage options that suit your needs and enter the amount requested for any benefits if applicable.
6. If you are applying for coverage for spouses, domestic partners, or children, fill out the dependent information section with their names, dates of birth, and gender.
7. Review the fraud warnings included in the document to ensure you understand the implications of providing false information.
8. Finally, in the declarations and signature section, confirm that all information is accurate and sign the form. Include the date of signing.
9. After completing the form, make a copy for your records. Return the original by mail to the specified address or fax it to the provided number. You may also save, download, or print the form for submission.

Take the next step today and complete your Enrollment Form online.