Get Instructions For Completing Employee Enrollment/change Form

Completing the Employee Enrollment/Change Form online is a straightforward process. This guide provides a clear, step-by-step approach to ensure that users can accurately fill out the necessary sections of the form.

Follow the steps to effectively complete your enrollment/change form online.

1. Click the 'Get Form' button to access the Employee Enrollment/Change Form and open it in your preferred online editor.
2. Begin with section one, which is designated for completion by your local Human Resource Office. Ensure that this section is filled out appropriately before proceeding.
3. In section two, enter your personal details. This includes your name, address, and contact information. Ensure that all fields are completed accurately.
4. Navigate to section three to select your medical plan option. Mark the box next to the plan you wish to enroll in, and, if applicable, provide the name of the health care plan along with the healthcare center or doctor's name.
5. In section four, indicate your preferred dental plan option by marking the appropriate field.
6. If you choose the Concordia Plus option in section five, select a primary dental office. Dependent family members may choose different offices if needed.
7. Proceed to section six for employee demographic data. Complete all applicable fields, but leave the 'CTY CODE' section blank for your Human Resource Office to fill.
8. Skip section seven; it is solely for your Human Resource Office's use.
9. In section eight, gather and complete information about your dependents, including their names, social security numbers, and birth dates. Include any health care center information as required.
10. Leave section nine blank as it is for Human Resource use only.
11. Sign the form in section ten to authorize the application for enrollment or change.
12. Next, record the date of your signature in section eleven.
13. Finally, section twelve is for the Human Resource Office's completion. Once everything is filled out and signed, save the final form. You can download, print, or share the document as needed.

Start completing your Employee Enrollment/change Form online today for a seamless process.