Follow the steps to complete your enrollment form seamlessly.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online platform.
2. Begin with Section 1, Enrollment/Notice of Change. Indicate the reason for completing the form by checking the applicable box. Options include New Enrollment, Medical Plan Change, or Add/Delete Spouse, among others.
3. Move on to Section 2, Participant Information. Fill out your last name, first name, middle initial, mailing address, home phone, social security number, and email address. Ensure to check if your address is new.
4. In Section 3, Medical Plan Selection, select the desired medical plan by marking the appropriate box. Be aware of the provider networks associated with the plan you are choosing.
5. Complete Section 4, Dental Plan Selection, by selecting either the Indemnity Dental Plan or a Prepaid Dental Plan. Indicate if you are a current patient of the selected dentist if applicable.
6. Proceed to Section 5 for Spouse/Domestic Partner Information. Fill in the necessary details, including name, date of birth, and any other medical coverage information if relevant.
7. In Section 6, Eligible Children, list all eligible children you wish to enroll. Make sure to use additional sheets if more space is needed, ensuring to provide all requested information.
8. If applicable, refer to Section 7 to Disenroll or Delete Dependents by listing dependents and their details.
9. Complete Section 8, Death Benefit Beneficiary Designation, by providing the necessary information about your chosen beneficiary.
10. Finally, in Section 9, Authorization and Verification, read the provided statements carefully. Sign and date the form to authorize your enrollment and any disclosures required.

Ready to proceed? Complete your enrollment form online for a smooth enrollment experience.