Get Allied Enrollment Application 2009-2025

Filling out the Allied Enrollment Application online is an essential process for enrolling in your employer's health benefits. This guide provides step-by-step instructions to help you complete the application accurately and efficiently.

Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to access the application form and open it in your preferred editing tool.
2. Begin by entering your employer's name, which in this case is 'Lake Villa School District #41', along with the Group Number 'A04121F'.
3. Next, fill in your personal information. Enter your name, address, city, state, zip code, date of birth, and marital status in the designated fields.
4. Provide your phone number in the specified section, ensuring it is accurate for future contact regarding your enrollment.
5. Indicate your enrollment status by selecting one of the options: 'Late Applicant', 'Special Enrollment', or 'Change in current member status'. Make the appropriate choice.
6. Select the medical plan coverage level that you wish to enroll in: 'Employee Only', 'Employee + Spouse', 'Employee + Child', or 'Family', depending on your circumstances.
7. If you or any of your dependents have other group medical coverage or Medicare, mark 'Yes' and provide the necessary details, including the name of the individual with other coverage and the insurance carrier or TPA.
8. If you are waiving your medical plan coverage, select the reason for declining enrollment, which could include 'Medicaid', 'Medicare', 'State Children's Health Insurance Program', 'COBRA', or 'Other'.
9. Review the certification statement at the end of the form, confirming that all information provided is accurate and that you understand the implications of refusing coverage for yourself and dependents.
10. Finally, sign and date the application to complete the enrollment process. Save your changes, and you may also download, print, or share the form as needed.

Complete your Allied Enrollment Application online today to ensure your health benefits are properly established.