Get Employee Action Form

Filling out the Employee Action Form online is a crucial step in managing your health plan benefits. This guide will walk you through the necessary steps to complete the form accurately and efficiently.

Follow the steps to effectively complete the Employee Action Form.

1. Press the ‘Get Form’ button to access the form and open it in your designated document editor.
2. Begin by filling in your personal information. Include your group name, last name, first name, middle initial, and social security number. This information is essential for identifying your records.
3. Provide details regarding your insurance company. Enter the group number, select your gender, input your birth date, and optionally fill out your ethnicity and primary language.
4. Complete your mailing address, including the city, state, and zip code. Make sure all the information is accurate to ensure proper communication.
5. Specify your primary care physician's name and indicate your marital status by selecting either 'Single' or 'Married'.
6. Fill in your home phone number, work phone number, hire date, and marriage date as applicable.
7. In the ACTION section, indicate what you wish to do: enroll, add a dependent, cancel a plan, cancel COBRA, cancel a dependent, or specify other actions.
8. Select the effective date for your action and provide a reason if necessary in the REASON section. Common reasons include divorce, birth, retirement, or loss of coverage.
9. If waiving coverage, mark the appropriate box and provide the reason for the waiver. Include any relevant details about existing coverage.
10. In the COVERAGE TYPE & ENROLLMENT INFORMATION section, choose your desired benefit plan if applicable and provide additional details about enrollment.
11. Complete the DEPENDENT INFORMATION section diligently for each dependent, filling in names, birth dates, and primary care physicians as required.
12. If you have out-of-area court-ordered dependents, list their details under the OUT OF AREA COURT ORDERED DEPENDENT section.
13. Answer the COORDINATION OF BENEFITS question by indicating if you or any listed family member has other insurance coverage. Provide details if applicable.
14. Sign and date the form at the bottom to confirm that all provided information is accurate and that you consent to the terms outlined in the document.
15. After completing the form, you can save your changes, download it, print a copy for your records, or share it as necessary.

Take the first step towards effective health plan management by completing your Employee Action Form online today.