Get Employee Enrollment / Refusal Form For Groups With 10 Or More ...

Filling out the Employee Enrollment / Refusal Form is essential for ensuring your benefits are accurately recorded under your employer's plan. This guide provides step-by-step instructions to help you navigate the online form efficiently.

Follow the steps to complete your enrollment or refusal form with ease.

1. Click the ‘Get Form’ button to obtain the form and open it in your document editor.
2. Begin by providing your personal information in the designated fields. Enter your last and first names, address, social security number, birth date, height, weight, and tobacco use status. Don't forget to list your phone numbers and email address.
3. Indicate the individuals who are electing coverage under your plan. Include their names, relationships to you, dates of birth, genders, heights, and any relevant health information if you are enrolling them.
4. Review the coverage options provided and check the appropriate boxes to indicate which benefits you are electing or declining for yourself and your dependents.
5. If you are declining any coverage, specify the reasons in the designated section of the form. Choose from the provided options such as Medicare, Medicaid, or other health coverage.
6. Complete the health statement only for those electing coverage. This involves answering questions regarding any health treatments, conditions, or disabilities for yourself and dependents.
7. Read through the notices regarding your rights and the terms of your enrollment finally. Once you are certain all information is accurate, sign and date the form.
8. After completing the form, you may save your changes, download the document, print it for your records, or share it with your employer as necessary.

Get started with completing your Employee Enrollment / Refusal Form online today to secure your benefits!