Get Assurant Self Funded Program Reviews Form

Completing the Assurant Self Funded Program Reviews Form is a crucial step for eligible employees seeking coverage. This guide provides clear and detailed instructions on how to effectively fill out the form online, ensuring a seamless enrollment experience.

Follow the steps to complete the form accurately and efficiently.

1. Click the ‘Get Form’ button to access the form and open it in the online editor.
2. Begin with Section A, titled 'Employee Information.' Fill in your full name, mailing address, phone numbers, email address, and citizenship status. Ensure that this information is accurate as it will be used for correspondence and coverage eligibility.
3. If enrolling in an existing plan or making changes, complete Section B. Specify the group's number and the requested effective date. Indicate if you are a new enrollee, making a coverage change, or adding dependents.
4. Proceed to Section C to list all family members to be covered. Provide their names, relationships to you, dates of birth, and social security numbers.
5. In Section D, complete the 'Medical History' section. Include your and your dependents' heights, weights, tobacco use history, and any prescribed medications over the last 18 months.
6. Carefully answer the medical history questions regarding past medical diagnoses, treatments, and hospitalizations for you and your dependents. Ensure that you provide additional details in Section E for any 'Yes' answers.
7. If waiving any coverage, complete Section F. List the individuals waiving coverage along with their other coverage carrier details.
8. In Section G, indicate if any current medical plan will remain active and provide the necessary details.
9. Finish by completing Section H, which requires your signature and date. Ensure you review all your provided information for accuracy before final submission.
10. Once the form is fully completed, save any changes made. You can then download, print, or share the form with the necessary parties.

Begin your enrollment process by completing the Assurant Self Funded Program Reviews Form online today.