Get Ee-ap-202-0713

The EE-AP-202-0713 form is essential for employee enrollment in an alternate funding health plan. This guide provides clear, step-by-step instructions to help users fill out the form accurately and efficiently online.

Follow the steps to complete the EE-AP-202-0713 form online.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by entering the enrollee's Social Security Number and Group Number accurately in the designated fields.
3. Fill in the enrollee information, including employer name, employer address (if applicable), last name, first name, marital status, address, phone number, and other personal details. Ensure all information is clearly printed.
4. Indicate the gender of the enrollee and provide the date of birth, including county, height, weight, email address, date employed full time, average hours worked per week, and occupation.
5. If applicable, provide dependent information by listing the details of each dependent under the enrollee’s care. Use lined paper if additional space is needed.
6. For the eligibility and other insurance section, check the appropriate boxes for current employment status, whether the enrollee plans to keep other insurance coverage, and provide details about any other existing insurance plans.
7. Complete the medical history section honestly, indicating if anyone has been diagnosed or treated for specific conditions within the last ten years.
8. Fill in the prior medical coverage information, noting any previous insurance plans and the reasons for termination of those plans if applicable.
9. If waiving coverage, complete the waiver section, specifying the reason for waiving coverage and any qualifying coverage details.
10. Sign and date the form in the required signature sections, ensuring that all necessary information is provided to avoid processing delays.
11. Finally, review the completed form for accuracy, save your changes, and choose to download, print, or share the completed form as needed.

Complete your enrollment forms online efficiently and accurately.