Get Under 65 Open Enrollment Election Form - Princeton University - Princeton

Filling out the Under 65 Open Enrollment Election Form is an essential step for eligible retirees seeking health care coverage at Princeton University. This guide will provide you with clear, step-by-step instructions to help you complete the form efficiently and correctly.

Follow the steps to complete the form online.

1. Click the ‘Get Form’ button to obtain the Under 65 Open Enrollment Election Form and open it for editing.
2. Begin by entering your personal information in the designated sections. Include your last name, first name, middle initial, Social Security number, employee ID number, date of birth, telephone number, and complete address, including the zip code.
3. In the health plan election section, check the box for the option you select: UnitedHealthcare Princeton Health Plan, Aetna Princeton Health Plan, Aetna HMO, or Waiver if you opt-out of coverage.
4. Next, if you are opting for vision coverage, indicate your choice by checking the appropriate option: Vision Services Plan (VSP) or Waiver.
5. If you are including dependents in your coverage, provide their information. For each dependent, fill out their name, date of birth, Social Security number, Medicare Health Insurance Claim Number if applicable, relationship to you, and select whether they are covered under medical and/or vision.
6. Review the statements at the bottom of the form, which outline your understanding of coverage waivers and your billing responsibilities. Ensure you understand these terms before proceeding.
7. Sign the form and date it to certify the information provided is accurate.
8. Finally, save your changes, and decide whether to download, print, or share the completed form as needed.

Take action now and complete your Under 65 Open Enrollment Election Form online.