Get Dependent Beneficiary Group Insurance Form

This guide provides a step-by-step approach to filling out the Dependent Beneficiary Group Insurance Form online. Follow these instructions to ensure you complete the form accurately and efficiently.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Enter the CIP benefit recipient name and Social Security Number (SSN) in the designated fields.
3. Fill out the dependent’s personal information in Section I, including effective date of enrollment, dependent SSN, last name, first name, middle name, birthdate, sex, and retirement date.
4. In Section II, check the box that reflects the dependent's Medicare status and provide any required Medicare numbers and dates if applicable.
5. Complete Section III by entering the dependent's address information. Include details for any other addressees if necessary.
6. In Section IV, identify the relationship of the dependent beneficiary to the benefit recipient by checking the appropriate box and note that supporting documentation is required.
7. Complete Section V by selecting the health plan and providing the name and plan carrier code if applicable.
8. In Section VI, indicate coordination of benefits and ensure any additional required documents are prepared for submission.
9. Review all sections for accuracy, then save your changes, download, print, or share the completed form as needed.

Complete your Dependent Beneficiary Group Insurance Form online today.