Get Employee Eligibility Statement - Starmark

The Employee Eligibility Statement - Starmark is an essential document that needs to be completed accurately to ensure proper enrollment in your employer's health plan. This guide will walk you through the online process of filling out this form, highlighting each section and field to ensure you complete it with confidence.

Follow the steps to fill out the Employee Eligibility Statement - Starmark online.

1. Click ‘Get Form’ button to access the Employee Eligibility Statement - Starmark and open it in your preferred digital format.
2. Begin filling in the Employer Information section by providing the company name, location (state and ZIP), plan choice if available, group number, physician/hospital network, and proposed effective date of coverage.
3. Proceed to the Employee Information section, ensuring to input your legal first name, middle initial, legal last name, address, work phone, home phone, email address, hours worked per week, date employed full-time, job title, marital status, and annual salary.
4. In the Coverage Information section, indicate whether you are applying for coverage or waiving it. If applying, specify the coverage type, reason for enrollment, and enter your employment termination date if applicable.
5. If waiving coverage, check the appropriate boxes and provide the reasons for declining coverage, including any government or private plans you may currently have.
6. Next, complete the Dependent Information section if you have dependents to be covered. Provide their names, birth dates, social security numbers, and gender.
7. In the Prior/Other Coverage section, indicate whether you or your dependents had prior major medical coverage within the last 12 months, and fill out the relevant details if applicable.
8. Fill in the Medical Information section, answering all questions related to tobacco use, medical history, and any treatment your dependents have received. Be thorough and accurate.
9. Lastly, ensure to sign and date the Agreement and Authorization section at the end of the form. Check all your entries for accuracy before finalizing.
10. You can now save your changes, download the completed form, print it out, or share it as needed.

Complete your Employee Eligibility Statement - Starmark online today to ensure your health plan enrollment.