Get New Enrollment / Transfer Form - Files Gmc Cc Ga

This guide provides clear and supportive instructions on completing the New Enrollment / Transfer Form for the State Health Benefit Plan in Georgia. By following the step-by-step guidance, users can efficiently fill out the form online.

Follow the steps to successfully complete your enrollment or transfer application.

1. Click the ‘Get Form’ button to obtain the New Enrollment / Transfer Form and open it in your document editor.
2. In Section I, provide your member identification details, including your Social Security Number, gender, date of birth, full name, telephone number, and address. Make sure all details are accurately filled out before proceeding.
3. Section II is for department or school system use only. It requires completion of details such as Payroll Location Number and Event Date, which should be filled by your HR.
4. In Section III, indicate your enrollment status by selecting either New Hire, New Enrollee, or Returning Member. Choose your health plan option by circling the appropriate choice among the available CIGNA or UNITEDHEALTHCARE plans.
5. Section IV requires answering questions related to tobacco use and spouse health coverage eligibility. Be honest as this may affect any applicable surcharges on your premium.
6. Complete Section V to choose your desired coverage tier. Carefully circle the appropriate option that reflects your chosen coverage level.
7. If you wish to cover dependents, fill out Section VI. Provide personal details for each dependent, including their name, relationship, sex, date of birth, and Social Security Number if applicable.
8. In Section VII, read the attestation statement carefully, sign and date it to confirm the provided information is accurate and complete.
9. After completing the form, save your changes. You can download, print, or share the completed form as required.

Complete your New Enrollment / Transfer Form online to ensure your health coverage needs are met.