Get Employee Medical Enrollment Form For New Plans Effective ...

This guide provides comprehensive instructions on how to complete the Employee Medical Enrollment Form for New Plans. This form is essential for enrolling in medical plans provided by your employer and requires accurate information for processing your coverage.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the employer's name, which is Solano Irrigation District, and ensure the effective date is clearly noted as December 1, 2016.
3. Select your marital status from the options provided: Single, Married, Registered Domestic Partner, Legally Separated, Divorced, or Widowed.
4. Provide your full name including last name, middle initial, and first name along with your social security number.
5. Enter your mailing address and contact phone number to ensure your employer can communicate with you.
6. Indicate your date of hire and date of birth, ensuring that these dates are accurate to avoid any delays.
7. Circle your current status as Active, Retired, or Director to inform your employer of your employment status.
8. Fill in the date of your marital status to indicate when the marital status change occurred (if applicable).
9. If you decide to waive medical coverage for yourself or your dependents, mark the appropriate box and prepare the Medical Declination Form.
10. Select the desired medical plans by checking the appropriate boxes for Anthem or Kaiser plans.
11. If applicable, fill out dependent information, including full names, dates of birth, and relationships to you, ensuring accuracy.
12. Provide any notes regarding your enrollment if necessary for better understanding or communication.
13. Complete the required signatures and date the form to confirm your enrollment choices and agreements.
14. Review your entries thoroughly for accuracy, then save your changes. You can also download, print, or share the completed form as needed.

Complete your Employee Medical Enrollment Form online to ensure your medical coverage is set up correctly.