Follow the steps to complete your enrollment application change form online.

1. Click ‘Get Form’ button to download the form and open it for editing.
2. Begin with Section 1, Enrollment Events. Select all applicable boxes to indicate if you are a new enrollee, adding a dependent, or making other changes. Provide the effective date for benefits and any special enrollment event details, if relevant.
3. In Section 2, provide your personal information, including your name and Social Security number, even if you are declining coverage.
4. Proceed to Section 3, Your Coverage. Complete all relevant sections regarding your chosen health and dental coverages, including the plan ID.
5. Move to Section 4, Coverage Options. Include your new primary care physician's details if applicable and specify any changes in your address or name.
6. If you have disabled dependents, fill out Section 5, providing the necessary information and certifications as mandated.
7. Complete Section 6 regarding any other health or dental coverage you or your dependents may have.
8. In Section 7, provide Medicare coverage details for you or any dependents, ensuring to include the necessary effective dates and relevant information.
9. If you are declining any coverage, fill out Section 8, detailing the reasons for declining coverage for yourself and your dependents.
10. Finally, review Section 9, Coverage Conditions. Sign and date the form to agree to the terms, then submit the completed form to your employer’s Enrollment Department.

Complete your enrollment application change form online today to ensure you receive the necessary health coverage.