Get Gn-99955-cg 2009-2025

This guide provides a detailed overview and step-by-step instructions for completing the GN-99955-CG form online. By following the instructions carefully, users can ensure that their information is accurately submitted for any necessary changes to their employee benefits.

Follow the steps to successfully complete the form.

1. Press the 'Get Form' button to access the GN-99955-CG form. Once you have retrieved the form, open it in the specified editor for online completion.
2. Begin by entering your current medical group number, benefit number, class/division, and dental group number, if applicable. It is important that you print clearly and fill in each applicable circle.
3. Indicate the proposed effective date for the changes. Enter the date using the format mm/dd/yyyy.
4. Fill in the company name and location, including the city and state.
5. Provide your personal information under the 'Employee Information and Changes' section. Fill out the last name, first name, middle initial, and social security number.
6. Select and fill in the necessary changes. Indicate any change to medical benefits, primary care physician selection for HMO/POS, dental benefits, life benefits, and any coverage cancellation. Be sure to include necessary additional information, such as physician IDs or beneficiary names as required.
7. Under the 'Qualifying Event Information', input the date of the qualifying event along with the reason for the changes. You can select from the listed reasons, such as marriage or dependent birth/adoption.
8. If applicable, fill in the address change information. Indicate whether the change applies to the employee only, all dependents, or specific dependents.
9. Complete the 'Dependent Changes' section for any changes regarding dependents. This includes filling in their names, social security numbers, relationships, and selecting any benefits for addition or deletion.
10. After reviewing all provided information, finalize your submission by digitally signing, entering the date, and providing the name and relationship of any legal representative, if necessary.
11. Once all information is filled out and verified, you can save changes to the form, download or print it for your records, or share as required.

Start completing the GN-99955-CG form online today to ensure your benefits are updated accordingly.