Get Employee Enrollment Application California - Copower

Filling out the employee enrollment application for California's CoPower program can be straightforward if you follow the necessary steps. This guide provides clear, user-friendly instructions to help you complete the application online with accuracy and confidence.

Follow the steps to successfully complete your enrollment application.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Start by completing Section A, which focuses on employee information. Enter your last name, first name, middle initial, and social security number, as this information is required. Make sure to provide your home address, city, county, state, and ZIP code. Indicate your marital status, phone number, and the number of dependents.
3. Fill in your domestic partner status and email address. Include your employer's name and address, your employment status (full-time or part-time), and the language of preference, if applicable.
4. Next, provide your occupation and hire date in MM/DD/YYYY format. Specify the number of hours you work per week and indicate if you have a disability.
5. Proceed to Section B to select the type of application. Choose between new enrollment, open enrollment, or family addition, as well as any applicable COBRA events.
6. In Section C, select your desired coverage categories — medical, dental, and vision. Make sure to check the options provided by your employer, and specify if you would like additional plans or options.
7. For each type of coverage selected, ensure you also indicate member coverage options, such as employee only or family, and provide contract codes if known.
8. Complete Section D by entering dependent information, including their ages and whether they will be covered under the plan. Remember to provide social security numbers for dependents as required.
9. In Section E, indicate if anyone applying for coverage is eligible for Medicare or covered by other insurance. Fill in all required details comprehensively.
10. If you choose to waive coverage, complete Section F by providing the necessary waivers and reasons for declining coverage.
11. Finally, in Section G, read through the terms, conditions, and authorizations carefully. Sign and date the application once you have confirmed all information is correct. You may then save changes, download, print, or share the completed form.

Get started on completing your employee enrollment application online today.