Follow the steps to complete your application accurately.

1. Click ‘Get Form’ button to access the MN Application To Change Insurance Coverage and open it in your preferred online form editor.
2. Provide your personal details in the Employee Information section. Fill in your name, birth date, Employee ID number, phone number, Social Security number, and email address. Ensure all fields are completed as this information is mandatory.
3. In the Medical Coverage section, select the coverage type that applies to you (employee-only or family coverage) and choose your medical carrier. For employee coverage, include your Primary Care Clinic ID number.
4. Indicate whether you or any dependents have Medicare coverage. If you answer 'Yes', ensure to complete Part C of the application.
5. Next, complete the Dental Coverage section. Choose your coverage type and dental carrier, ensuring any additional dependent information is filled out as necessary.
6. In the Dependent Information section, list all dependents by providing their names, birth dates, genders, addresses, and Social Security numbers. You may add additional dependents if required.
7. Complete Part A regarding changes in coverage. State the life event that prompted the changes and ensure to provide the date of the event.
8. In Part B, answer the questions related to your spouse's eligibility for coverage. Based on your responses, SEGIP staff will determine eligibility.
9. If applicable, fill out Part C with Medicare information by providing the name, type of coverage, Medicare number, and effective date for any enrolled member(s).
10. Review and sign the Important Plan Information and Employee Authorization section, affirming the accuracy of your information and understanding your responsibilities.
11. Once the form is complete, save your changes. You can print the application, download it, or share it as needed.

Complete your MN Application To Change Insurance Coverage online today to ensure timely processing of your changes.