Follow the steps to complete your application with ease.

1. Click ‘Get Form’ button to obtain the application and open it in your preferred online editor.
2. In the employer section, fill out the Group/Billing Unit Number, Department Number, and Effective Date. Ensure that the Employer Name and Address are complete and accurate.
3. Move to the Employee Information section. Enter your full name (first and last), Social Security Number, and provide details about your address and contact information.
4. Specify your employment status by selecting from Full-Time, Part-Time, Retiree, or COBRA. Fill in your Hire Date and Birthdate, and indicate your gender and marital status.
5. In the Members/Enrollees Covered section, indicate who you wish to cover. This includes selecting coverage for yourself, your spouse, and any children, as well as entering specific details for each member.
6. If applicable, describe any significant events or reasons for changing your contract, such as marriage, divorce, or birth/adoption. Provide the date of the event.
7. For Medicare coverage, fill in the name of the person covered by Medicare, the effective dates, and the Medicare ID number.
8. Indicate whether you or your dependents will keep other health coverage and complete the necessary information if applicable, such as policy numbers and employer details.
9. Answer questions regarding any prior health coverage and timelines for enrollment based on previous coverage and current family situations.
10. If waiving coverage, select your reason and provide an acknowledgment of your waiver.
11. Finally, review the Authorization and Certification section carefully. Sign and date the form at the bottom to confirm your understanding and agreement with the provided terms.
12. After filling out the form, ensure all information is complete. Save changes, download, print, or share the form as needed.

Complete your Wellmark N-5408 - Group Application online today and ensure your health coverage is secured.