Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by entering your details under 'Employee enrolled in a CIGNA HealthCare plan.' Include your name, address, and CIGNA HealthCare Group and Member ID numbers.
3. Next, provide the first and last names of all dependent children in the designated fields, numbering them from 1 to 6.
4. Indicate who has legal custody of the dependent children by choosing the appropriate option.
5. Answer whether any dependent children live with you. If 'No,' provide the name, date of birth, and address of the parent or guardian with whom the dependents reside.
6. Determine if the parent without legal custody is obligated by a court decree to cover health care expenses. Respond accordingly.
7. If applicable, attach a copy of the court order assigning financial responsibility for medical or dental care.
8. Provide the name and social security number of the parent required to provide health care coverage, along with information on whether the coverage is through an employer.
9. If coverage is through an employer, fill in the employer's name and address.
10. Finally, provide details about any other health care carrier, including the carrier's name, policy number, and address.
11. Review your form for completeness, and then sign and date it at the bottom.
12. After filling in all fields, print the form by clicking the button at the end of the form or using your web browser's print function and mail it to the CIGNA HealthCare Claims Center.

Complete your documents online to ensure efficient processing of your claims.