Get Designated Eligible Individual Enrollment Form - Michigan ...

Navigating the Designated Eligible Individual Enrollment Form is essential for Michigan Tech employees looking to enroll a designated individual for health coverage. This guide provides clear, step-by-step instructions to help you complete the form online with confidence and ease.

Follow the steps to fill out the form online.

1. Press the ‘Get Form’ button to acquire the form and open it in your online editor.
2. Begin by entering the name of the designated eligible individual in the field labeled ‘Name (Last, First, MI).’ Ensure that the name is accurate, as this information is crucial for identification.
3. Input the social security number (SSN) of the designated eligible individual carefully to avoid any errors that may delay processing.
4. Fill in the date of birth of the designated individual. This information is necessary to verify eligibility.
5. Select the gender of the designated eligible individual by marking either 'M' for male or 'F' for female.
6. In the relationship section, specify the nature of your relationship with the designated individual.
7. Choose the enrollment type by indicating whether the enrollment includes medical, dental, and/or vision coverage.
8. If applicable, input the names of any children of the designated eligible individual in the subsequent lines provided.
9. Read the certification statement carefully. Ensure you understand that providing false information may result in disciplinary action.
10. Sign and date the form in the designated fields to confirm your application. Your signature indicates your acknowledgment of the criteria and your responsibility for any related tax obligations.
11. After completing all sections of the form, save your changes and prepare the document for submission.
12. Submit the completed form to Benefits Services either via secure sealed mail or fax to (906) 487-3220. Remember, do not send the form via email as it is not secure.

Complete your Designated Eligible Individual Enrollment Form online today to ensure timely processing and coverage.