Get Network Health Assure Self-insured Application And Change Form 2019-2025

This guide provides a step-by-step process for users to complete the Network Health Assure Self-Insured Application And Change Form online. Whether you are applying for coverage or making changes to your existing plan, this document will help you understand each section and field effectively.

Follow the steps to complete the form with ease.

1. Click the ‘Get Form’ button to access the form online.
2. Enter the name of your employer in the designated field.
3. Fill in the date of full-time employment and your group number/class.
4. Specify the effective date or date of change by selecting it from the calendar feature.
5. Indicate your coverage choice by selecting the appropriate checkbox for HMO, POS, or other options.
6. Declare the reason for your application/change, whether it be new subscriber, address change, adding a dependent, or other reasons.
7. In the employee information section, provide your last name, legal first name, nickname, and middle initial.
8. Complete your status by selecting single or married, along with your contact details including address, city, state, zip code, and email.
9. Fill out the enrollment section by providing information for yourself and any dependents, including their names, birth dates, social security numbers, and relationships.
10. Complete the section for other insurance coverage, indicating whether you or your dependents have additional medical insurance.
11. Review the confidentiality statement and ensure you understand its implications before signing.
12. Finally, either save the form, download it, print it, or share it as needed.

Complete your Network Health Assure Self-Insured Application And Change Form online today!