Get Po Box 4100

Filling out the Po Box 4100 form is an essential step for retirees to select their benefit options effectively. This guide provides detailed instructions to help users complete the form accurately and confidently.

Follow the steps to complete the Po Box 4100 form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with Section 1, where you will select your coverage options. Review the available medical and dental plans carefully. Ensure that your selections align with your current eligibility to avoid any issues.
3. Move to Section 2, where you will provide your personal information. Fill in your last name, first name, middle initial, gender, mailing address, date of birth, member ID number or social security number, city, state, current marital status, union local number, zip code, and contact information including cell phone and email address.
4. Proceed to Section 3 for spouse, domestic partner, and dependent children information. If you have additional dependents, be prepared to provide their details, including their last names, first names, relationships, genders, dates of birth, and social security numbers.
5. In Section 4, if applicable, note your beneficiary of the death benefit. It is important to select a beneficiary if you are a self-pay retiree.
6. Complete Section 5 by reading and signing the Member/Participant Certification. This section includes important information regarding fraud, disclosure of information, and arbitration. Ensure you sign and date the document.
7. After filling in all sections, review the form for accuracy. Make any necessary corrections.
8. Finally, save your changes, and choose to download or print the form for your records. Ensure to submit it as per the instructions provided at the end of the form.

Complete your documents online today to ensure a smooth enrollment process!