Get Small Employer Member Change Form - Rogers Benefit Group

Filling out the SMALL EMPLOYER MEMBER CHANGE FORM online can streamline the process of updating your information with Rogers Benefit Group. This comprehensive guide will provide you with clear, step-by-step instructions to ensure that each section is completed accurately.

Follow the steps to accurately complete the form.

1. Press the ‘Get Form’ button to access the SMALL EMPLOYER MEMBER CHANGE FORM and open it in your preferred editor.
2. In the employer section, provide the name of the employer and the group number in the designated fields. Be sure to specify the effective date of the changes by selecting the appropriate year, month, and day.
3. Indicate the changes in coverage by filling in the necessary fields for subgroup, product, class, and network changes with their respective dates.
4. If applicable, fill out the member's election for Minnesota Continuation (COBRA) by selecting the appropriate event date and reason.
5. In the employee section, enter the legal name of the employee along with their date of birth and social security number, which is required for federal reporting.
6. Provide the employee's contact details including their street address, city, state, ZIP code, telephone number, email, and county.
7. If there are any demographic changes, update the new address and telephone number fields as necessary.
8. If cancellations are needed, select the appropriate options for coverage cancellation while providing the reason for each cancellation.
9. For additions, indicate if you're adding medical or dental coverage to dependents by providing each dependent's name and social security number, and select an appropriate reason for addition.
10. Complete the health information section for both the employee and any covered family members by answering all relevant medical history questions.
11. Provide medication details and any dependencies regarding incapacity as required.
12. After filling out all sections, ensure that you sign and date the form at the designated signature lines.
13. Upon completion, you can choose to save changes, download, print, or share the form as needed.

Begin completing your SMALL EMPLOYER MEMBER CHANGE FORM online today to ensure your information is up to date.