Get Application For Enrollmentchange For Groups 1-50

The Application For Enrollment/Change for Groups 1-50 is essential for managing group health insurance enrollments efficiently. This guide provides clear, step-by-step instructions for completing the form online, ensuring a seamless process regardless of your experience level.

Follow the steps to fill out the application accurately and efficiently.

1. Click ‘Get Form’ button to access the Application For Enrollment/Change for Groups 1-50 online and open it in your preferred editing tool.
2. Fill in the group administrator information in the designated boxes, including health group number, subgroup, class, group name, and requested effective date.
3. Select whether this application is for new enrollment, change, or cancellation in Section 1. Specify the reason for enrollment, changes, or cancellation.
4. Complete the plan selection section by choosing the appropriate medical and dental plans that fit the applicant's needs.
5. Provide employee information, including name, address, telephone number, e-mail address, gender, and date of birth in Section 3.
6. If applicable, enroll dependents by providing their names, relationship, birthdates, and whether they have other group coverage in Section 4.
7. Indicate custody information for any children listed if relevant. Ensure that all information provided is clear and accurate.
8. Disclose any current or prior coverage in Section 6, detailing insurance carrier information and effective dates.
9. Complete the tobacco abstinence certification statement in Section 7, and verify if the applicant is a tobacco user.
10. Consent to electronic distribution of communications by signing in Section 8, or elect to receive paper communications.
11. Finally, sign and date the application in Section 9, confirming that all information is accurate and complete.
12. Once all sections are complete, save changes, download a copy, print the document, or share it as necessary.

Complete your application online today for a smoother enrollment experience.