Get Employee Enrollment / Change Form Initial Group Cobra Open Enrollment Benefits Administered By: Umr

The Employee Enrollment / Change Form is essential for new and existing employees to enroll in or make changes to their COBRA benefits administered by UMR. This guide will help you complete the form accurately and efficiently, ensuring a smooth enrollment process.

Follow the steps to properly fill out your form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred PDF editor.
2. Begin by filling out your personal information. This includes your first name, middle initial, last name, Social Security number, date of birth, and address. Make sure all details are accurate to ensure proper identification.
3. Indicate your current employment status by providing the employer name, group number, and employee start date. You will also need to specify your employee location and hours worked weekly.
4. Select your gender and marital status from the options provided. This information is often required for benefit eligibility and calculations.
5. Provide your email address and home telephone number. Ensure that the contact information listed is current, as this will be used for communication regarding your benefits.
6. Answer the question regarding other health coverage. If applicable, complete the additional fields with information about the other health plan, including the coverage level.
7. If you are electing dependent coverage, fill in the required details for each dependent, including names, birth dates, and relationships to you.
8. If you are making changes, indicate the effective date of the change and specify the changes in the appropriate section. This includes name changes, address updates, or adding/removing dependents.
9. For those waiving coverage, check the box indicating you are declining health coverage and sign the form to attest to this decision.
10. Before submitting the form, review all information thoroughly for accuracy. Save your changes, and then download, print, or share the completed form as needed.

Complete your documents online today to ensure your benefits are properly managed!