Get C15390-h-rev1-16 Core Employee Enrollment Application - Health - Revision

This guide provides step-by-step instructions on completing the C15390-H-REV1-16 Core Employee Enrollment Application for Health online. By following these guidelines, you can ensure that your application is filled out accurately and submitted without delay.

Follow the steps to complete the application online.

1. Click the ‘Get Form’ button to access the application and open it in your online editing tool.
2. Select the reason for the application by checking the appropriate box, such as 'Loss of coverage', 'Open enrollment', 'New hire', or 'Other qualifying event type'. Enter the date of the relevant event next to the selected reason.
3. Review Section 1 regarding important enrollment guidelines for Specialty Benefits coverage. Note that you can enroll in dental and vision plans independently.
4. In Section 2, choose your plan(s) by selecting the appropriate checkboxes for the medical, dental, and vision plans you wish to enroll in.
5. Complete Section 3, which requires your personal information. Fill in your full name, Social Security number, employment status, job title, home address, contact information, and other requested personal details.
6. Indicate your language preference and contact method. Specify if you are enrolling any dependents by checking ‘Yes’ or ‘No’.
7. If you are enrolling dependents, complete Section 4 with their information, including names, Social Security numbers, and the plans they are enrolling in.
8. Provide any necessary Medicare information in Section 5, including whether you or any dependents are covered by Medicare.
9. Sign and date the authorization section in Section 6 confirming that all provided information is accurate and complete.
10. Finally, ensure all sections are completed, then save your changes, download the document, print it for your records, or share it as required.

Complete your enrollment application online today to ensure timely processing of your benefits.