Follow the steps to complete the form successfully

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin with section 1, where you will need to provide the policyholder's information. Enter the policyholder's name, social security number, address, and telephone number.
3. In section 2, fill out the insurance information. Provide the name of the insurance company, claim mailing address, phone number, policy number, and policy group number. If no insurance is available, note it in this section.
4. Move to section 3 to list all individuals who can be covered under the policy. Enter their names, birthdates, and their Medicaid eligibility status. Check 'Yes' or 'No' appropriately and provide Medicaid ID numbers as required.
5. Answer question 4 by indicating whether the policyholder is currently enrolled in this insurance policy.
6. For question 5, specify whether any dependents are enrolled in the policy.
7. In question 6, indicate the current employment status of the policyholder.
8. Question 7 asks if the policy is through an employer, a former employer, or if it is privately purchased. Select the appropriate option.
9. For question 8, provide the amounts for medical, dental, and vision premiums.
10. Indicate how the premiums are paid in question 9, whether through payroll deductions or directly to the insurance company or employer.
11. In question 10, specify the frequency of the premium payments, such as monthly, biweekly, or quarterly.
12. Enter the next premium due date in question 11.
13. Finally, in section 12, provide information about the employer or former employer, including their name, address, and telephone number.
14. After filling out the necessary fields, ensure you sign and date the application at the bottom of the form.
15. Once all changes are saved, you can download, print, or share the completed form as needed.

Complete your application online to ensure prompt processing and access to benefits.