Get Group Enrollment Application Change Form

This guide will help you fill out the Group Enrollment Application Change Form online with ease. By following the provided instructions, you can effectively complete your application or changes to your enrollment.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Carefully read the instructions provided inside the form to understand the requirements before you start filling it out.
3. In Section 1, check all applicable boxes to indicate whether you are a new enrollee, adding a dependent, or making changes to your coverage. Fill in related information as needed.
4. Complete Section 2 with your personal details, even if you are opting out of coverage.
5. In Section 3, select your desired coverage options, ensuring to include the plan ID where required.
6. Fill out Section 4 with relevant coverage options, including selecting a primary care physician if applying for HMO coverage.
7. If claiming a disabled dependent, complete Section 5, ensuring all required documentation is attached.
8. Complete Section 6 if you or your dependents have any other health coverages that won’t be canceled.
9. If applicable, fill out Section 7 with your Medicare information.
10. If you are declining coverage, ensure Section 8 is filled out comprehensively.
11. Finally, sign and date Section 9 to agree to the coverage conditions before submitting the form to your employer's Enrollment Department.

Complete your Group Enrollment Application Change Form online today for a smoother enrollment experience.