Get Plan Name: Eo Es Division Of Insurance Ec Ef Colorado Uniform Employee Application For Small Group

Filling out the Colorado Uniform Employee Application for Small Group health benefit plans is essential for securing health coverage. This guide provides clear and supportive instructions to help users complete the application accurately and efficiently.

Follow the steps to successfully complete the online application.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Navigate to the coverage information section. Indicate the application type by selecting one of the following: New Coverage, Change/Modification to Existing Policy, Open Enrollment, or Special Enrollment.
3. Proceed to the employer information section. Fill in your Employee Name, Employer Name, Proposed Effective Date, and Group Number if known.
4. In the employee information section, type or print using black or blue ink. Complete fields such as First Name, Middle Initial, Last Name, Social Security Number, Date of Birth, Current Age, and Address.
5. Specify your job title and contact information, including home and work phone numbers, email address, and average weekly work hours. Indicate marital status by checking the appropriate option and answer whether you are on COBRA or State Continuation, providing start and stop dates if applicable.
6. In the health coverage section, list all dependents applying for coverage. Select the type of health insurance coverage you are applying for: Employee Only or Employee & Family.
7. In the dependent information section, enter each dependent's name, sex, social security number, relationship to you, whether they are disabled, and their birth date.
8. Complete the tobacco use section by answering whether anyone named in the application has used tobacco products in the last six months. Provide relevant details if applicable.
9. If you are not enrolling yourself or your dependents, complete the employee/dependent waiver of coverage, providing reasons for the waiver.
10. Fill out the Medicare information section if relevant, indicating coverage status for you and your dependents.
11. In the current medical coverage section, provide details about any health insurance coverage that you or your dependents currently have.
12. If applicable, select a primary care physician and enter their information in the health provider or product selection section.
13. Review the Terms and Conditions section. Certify the application by signing and dating at the bottom.
14. Once the form is fully completed and reviewed, save changes, download, print, or share the form as needed.

Complete your Colorado Uniform Employee Application online today to ensure your group health coverage.