Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the Network Health Assure Self-Insured Application and Change Form and open it in your designated editor.
2. In the first section, input your employer’s name and the date of your full-time employment accurately.
3. Fill in your group number or class and the effective date or date of change related to your application.
4. Specify the coverage you are applying for, selecting from options such as EPO, HMO, or POS, and indicate the reason for your application or change—this could include new subscriber, address change, add dependent, or other reasons.
5. For each dependent you wish to add, provide their name, birth date, sex, Social Security number, and indicate if they are a current patient of a primary care practitioner.
6. In the other insurance coverage section, answer whether you or any dependents have other medical insurance, indicating the name of the insurance provider and policy number if applicable.
7. Review the confidentiality statement closely, ensuring you understand the implications of your answers, and follow the instructions for providing the necessary signatures.
8. Finally, save your changes, and choose to download, print, or share the completed form as needed.

Begin filling out your Network Health Assure Self-Insured Application and Change Form online today!