Get Gahp Duluth Continuation Of Coverage Form - Shb Umn

The GAHP Duluth Continuation Of Coverage Form - Shb Umn allows plan members to request continuation of their health coverage after losing eligibility. This guide will provide clear instructions on how to complete the form online, ensuring you understand each section and field.

Follow the steps to successfully complete your form online.

1. Press the ‘Get Form’ button to access the GAHP Duluth Continuation Of Coverage Form. This will open the document for you to begin filling it out.
2. In Section A, provide your graduate assistant information. Fill in your full name, date of birth, gender, U of M ID number, street address, city, state, ZIP code, daytime phone number, and UMN email address. Indicate if you wish to continue coverage or dependent coverage by selecting the appropriate boxes.
3. Proceed to Section B to enter dependent enrollment information. Select the appropriate plan for coverage and list the names, dates of birth, relationship (spouse or child), genders, and social security numbers of your dependents. Ensure all dependents are listed under the same plan.
4. In Section C, sign and date the form where indicated to confirm your request for continuation of coverage. Remember, only handwritten signatures are accepted.
5. If you have dependents, move to Section D to calculate your total amount due. Sum the GA coverage and your selected dependent coverage for the first two months of payment.
6. Select your preferred payment method in Section E. Options include enclosing a check or money order, authorizing monthly credit card charges, or opting for monthly payment coupons.
7. If relevant, complete Section F by providing your credit card information. Fill in your name, U of M ID number, credit card type, account number, expiration date, and an authorizing signature.
8. Once all sections are completed, review your form for accuracy. Then, save any changes made, download a copy for your records, and print or share the form as needed.

Complete your GAHP Duluth Continuation Of Coverage Form - Shb Umn online today to ensure your health coverage continues without interruption.