Follow the steps to successfully complete the enrollment form.

1. Press the ‘Get Form’ button to acquire the HRA Enrollment Form and open it for editing.
2. Begin with the ‘Type of Activity’ section by selecting from the options provided: New Hire/Open Enrollment, Re-Hire, or COBRA Elect. Enter the date coverage begins in the designated format.
3. Fill out the ‘Employee Information’ section, including your first name, last name, mailing address, date of birth, middle initial, apartment/suite number, gender, daytime phone number, social security number, email address, state, and zip code.
4. In the ‘Elected Coverage(s)’ section, confirm the HRA selection and choose the type of coverage, such as Employee Only, Employee/Spouse, Parent/Child, or Family.
5. Complete the ‘Employee Enrollment Authorization’ section by certifying the accuracy of the provided information and signing the form. Remember to include the date.
6. For the ‘Covered Dependent Information’ section, fill out the necessary details for each dependent, including their first name, last name, mailing address, date of birth, relationship, social security number, gender, and any required apartment/suite numbers.
7. If you wish to enroll for the mySourceCard™ or set up direct deposit, carefully follow the instructions provided in the respective sections. Ensure all required fields are completed and any necessary attachments, such as voided checks, are included.
8. Review all entered information for accuracy before submitting the form. Once verified, you can save the changes, download a copy for your records, or print the completed form.

Take the next step towards your benefits—complete the HRA Enrollment Form online today.