Get Enrollment/change Form Life/dental/disability/vision ...

Completing the enrollment/change form for life, dental, disability, and vision coverage is essential for securing your benefits. This guide will provide you with clear and supportive instructions to ensure a smooth online submission process.

Follow the steps to complete the enrollment/change form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out your personal information, including the planholder name, your name, and contact details. Ensure that all information is printed clearly in black or blue ink.
3. In Section 1, check the appropriate box to indicate whether you are adding an employee, reporting a new hire, or applying due to a loss of other coverage. If required, complete Section 5.
4. Select your desired coverage options. Indicate whether you are enrolling yourself, your spouse, or your children for life, dental, vision, and disability insurance. Choose only one option for dental plans where applicable.
5. Complete additional sections for adding or dropping dependents or coverage. Make sure to provide necessary information for any changes, including names and social security numbers.
6. If you are refusing coverage, complete Sections 2, 4, and 6. Clearly indicate your reasons for refusal and provide required details about any prior coverage.
7. Fill out the beneficiary designation section by providing the full name and relationship of the designated person. Ensure accuracy to avoid complications later.
8. Review the form thoroughly for completeness and accuracy before submitting. Ensure that all signatures and dates are included.
9. Once everything is filled out correctly, you can save changes, download a copy of the document, print it for your records, or share it as needed.

Encouragement to complete your enrollment/change form online today for a hassle-free experience.