Follow the steps to successfully complete the enrollment form.

1. Click ‘Get Form’ button to procure the enrollment form and open it in the editing tool.
2. Begin by providing your personal information in Section A. This includes your first name, middle initial, last name, street address, city, state, zip code, phone numbers, and social security number or employee ID number.
3. Indicate your employment details, including how many hours you work per week, and provide information about your primary physician.
4. In Section B, list any dependents you wish to enroll, change, or cancel. For each dependent, fill out their name, social security number, birthdate, relationship to you, and coverage type preference.
5. In Section C, select your desired coverage types. Ensure you check the appropriate boxes for medical, dental, and vision plans, and indicate any specific plan selections that apply.
6. If you are waiving medical coverage, complete Section E by checking the reason for the waiver and providing your signature and date.
7. In Section D, provide any other medical coverage information, including details about other policies you or your dependents may have, coverage start and stop dates, and names of family members covered under these plans.
8. Finally, review all information for accuracy. You can then save the changes, download a copy of the completed form, print it, or share it as required.

Start filling out your enrollment form online to ensure you receive the necessary healthcare coverage.