Get Group Enrollment Form Do Not Use - Internal

Filling out the Group Enrollment Form is an essential step for users looking to enroll in health plans. This guide provides clear instructions to ensure the form is completed accurately and efficiently.

Follow the steps to complete your Group Enrollment Form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Complete the Group Employer Information section. This is required by the Group Benefits Administrator and must include the Employer Name, Group Number, Subscriber Status, and the Administrator's signature. Use blue or black ink and print clearly.
3. Fill out the Subscriber Plan section. Indicate the department number and select the applicable plan options. Be sure to check the coverage type, whether it is for single, spouse, or dependent(s).
4. Provide the reason for enrollment or change in the designated section. Select from options such as new hire, open enrollment, or other reasons as applicable.
5. Complete the Subscriber Information section, including the subscriber's name, contact information, date of birth, and Medicare number if applicable. Ensure to sign the form at the end.
6. Fill out the Other Coverage Information if applicable, mentioning previous coverage with Excellus BlueCross BlueShield or other insurance, along with the required details.
7. Indicate Cancellation Information, if needed, by identifying the subscriber or dependent being canceled and the reason for cancellation.
8. Input the Dependent Information for all persons to be covered, ensuring to include names, date of births, social security numbers, and other necessary details.
9. Review the Release/Signature section. The subscriber must read and confirm all information is accurate before signing and dating the form.
10. After completing the form, ensure all fields are filled correctly, then save your changes, download, print, or share the form as required.

Complete your Group Enrollment Form online now for a smooth enrollment process.