Get Broome Tioga Delaware Consortium P Group Enrollment Form

Filling out the Broome Tioga Delaware Consortium P GROUP ENROLLMENT FORM online can be a straightforward process when you have the right guidance. This guide will help you navigate each section of the form step by step, ensuring that you provide all necessary information clearly and accurately.

Follow the steps to complete your group enrollment form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by completing the Group Employer Information section. This section must be filled out by the Group Benefits Administrator. Provide the Subscriber Status, Group Number, Subgroup Number, Employer Name, and any applicable reasons for COBRA. Sign and date this section where indicated.
3. In the Subscriber Plan section, enter the Employee Number and Department. Check the applicable plan(s) and coverage type for the subscriber and any dependents. Use blue or black ink and ensure you print clearly.
4. Indicate the Reason for Enrollment or Change. Refer to the list provided and select appropriate reasons such as New Hire, Loss of Coverage, or adding a dependent. Ensure all applicable reasons are checked.
5. Complete the Subscriber Information section. Fill in the subscriber’s last name, first name, middle initial, email address, mailing address, phone numbers, date of birth, and marital status. Ensure you provide accurate and complete information.
6. Provide information regarding Other Coverage. Answer the questions about previous memberships and other insurance details. If applicable, provide a copy of the Certificate of Coverage.
7. If any cancellation is necessary, complete the Cancellation Information section. Indicate who is being canceled and the reason for cancellation.
8. List Dependent Information for each person to be covered under the plan, including their names, dates of birth, and social security numbers. Fill in all required fields for dependents.
9. In the Release/Signature section, ensure the subscriber signs and dates the form. This step is crucial for the processing of the application.
10. After filling out the form, review all entries for accuracy. Save changes, and then choose to download, print, or share the completed form as needed.

Start completing the Broome Tioga Delaware Consortium P GROUP ENROLLMENT FORM online now to ensure timely processing of your enrollment.