Get Family Health Statement Form - Ct.gov - Ct

Filling out the Family Health Statement Form is an essential step for ensuring comprehensive health coverage for you and your dependents. This guide provides clear instructions on how to complete the form effectively and accurately.

Follow the steps to successfully complete the Family Health Statement Form.

1. Press the ‘Get Form’ button to obtain the Family Health Statement Form and open it in your chosen editor.
2. Begin by entering the name of your employer and the employer's address, including the street, city, state, and zip code.
3. Fill in the policy number and your occupation. Additionally, provide the date of full-time hire and the average number of hours worked per week.
4. If you choose not to enroll due to having other group health coverage, indicate this by checking the appropriate box for yourself, spouse, or dependent children.
5. Sign and date the form to confirm that the information provided is accurate to the best of your knowledge.
6. Complete all required fields for each family member applying for coverage. This includes their full name, relationship to you, date of birth, height, weight, sex, and whether they are a full-time student.
7. Provide the social security number and marital status of the employee, selecting either single or married.
8. Answer the eligibility questions regarding current health coverage, disability status, and previous medical history for you and your dependents.
9. Ensure any additional remarks or information are filled out, especially if there are conditions to disclose as outlined in the form.
10. Review the completed form for accuracy. Save your changes, download a copy, print it, or share as needed.

Start completing the Family Health Statement Form online today for comprehensive health coverage.