Get Transmittal Form

This guide offers a clear and comprehensive approach to completing the Transmittal Form online. Whether you are enrolling, changing, or canceling your group insurance, this document helps you navigate each step confidently.

Follow the steps to successfully complete your Transmittal Form

1. Press the ‘Get Form’ button to access the Transmittal Form and open it in your browser.
2. Begin by filling out the group number at the top of the form. Make sure to enter the correct group number to avoid processing delays.
3. In section A, provide your employee information. Enter your first name, middle initial, and last name as they appear on official documents. Indicate if you are enrolling, canceling, or changing your street address.
4. Complete the remaining fields in section A, including your Social Security number, address, city, state, zip code, email address, and phone numbers. Ensure all information is accurate to prevent issues.
5. In section B, list all dependents to be covered. For each dependent, provide their first name, middle initial, last name, Social Security number, sex, birth date, and indicate if they are a full-time student.
6. For section C, select your medical plan if applicable. Indicate your choice clearly to ensure the correct plan is processed.
7. If you or your dependents do not want medical coverage, fill out section D. State the reason for declining coverage and ensure you provide your signature.
8. Complete section E concerning any other health insurance coverage you or your family members may have. This helps in coordinating benefits.
9. Provide any required Medicare information in section F, including details about the Medicare coverage of you or your dependents.
10. Read and sign section G for employee authorization and representation. Ensure you understand the terms before signing.
11. Finally, if you are an employer representative, complete section H. Review all sections of the form for accuracy before submitting.
12. After filling out all sections accurately, save your changes, then download, print, or share the completed form as required.

Complete your documents online for a smoother processing experience.