Get C12914-ff 4-17 Sbm-employeeapplication-fillable

This guide provides a clear and comprehensive overview of how to complete the C12914-FF 4-17 SBM-EmployeeApplication-Fillable form online. It is essential to fill out this application accurately to ensure timely processing of your enrollment.

Follow the steps to successfully complete your employee application.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your subscriber information in the designated fields. Ensure all details, including last name, first name, middle initial, and social security number are completed, as missing information may delay processing.
3. Indicate the reason for your application by selecting one or more checkboxes: New group enrollment, new hire/rehire, open enrollment, COBRA/Cal-COBRA enrollment, new spouse/dependent, or other qualifying event. Provide necessary dates where applicable.
4. In Section 1a, select your health plan from the options provided. You can choose from various packages like HSA-compatible HDHP plans, Access+ HMO plans, and PPO plans. Please be sure to mark the appropriate checkbox for your chosen plan.
5. Proceed to Section 1b for Specialty Benefits selection. If offered by your employer, complete the attached Specialty Benefits Employee Benefit Selection Form for dental, vision, and life insurance coverage.
6. Fill out the necessary sections for any dental and vision plans under Sections SB1 and SB2. Mark the appropriate options for your desired coverage.
7. Section SB3 requires you to provide your employee information for the life/ad&d insurance plan. Fill out your job title, average hours worked per week, and the designation of beneficiaries along with their respective details.
8. Complete Section 2 by providing detailed subscriber information, including home address, contact details, email address, preferred contact method, and marital status.
9. If you're selecting an HMO plan, fill out Section 3 to assign a Personal Physician by answering yes or no regarding the designation request.
10. In Section 4, provide information about any dependents you wish to enroll and complete the required fields. Make sure to check the enrollment status for dependents.
11. If applicable, complete Sections 5 and 6 for other health plan information and Medicare information, ensuring to attach any required documentation.
12. If enrolling due to COBRA or Cal-COBRA, fill out Section 7 with all required details about previous coverage.
13. Read and acknowledge the disclosure of personal and health information in Section 8. Sign and date where indicated.
14. Finally, review all information for accuracy. Users can then save changes, download, print, or share the form as necessary.

Complete your application online today to ensure your coverage is processed without delay.