Get Initial Enrollment Form For Active Employees And Non ... - Mass.gov

Completing the Initial Enrollment Form for Active Employees and Non-Medicare Retirees/Survivors is an essential step for individuals enrolling in health insurance coverage. This guide offers clear and supportive instructions to assist you in accurately filling out the form online.

Follow the steps to complete your enrollment form accurately.

1. Click the ‘Get Form’ button to access the enrollment form and open it in your editing tool.
2. Begin by entering your Insured’s GIC-ID, typically your Social Security number, in the provided field. Also fill in your Department ID number or Agency/Division number.
3. Select one option that describes your status, such as 'Active Employee', 'Retiree', 'Survivor', or 'COBRA', and enter any relevant dates as required.
4. Input your date of birth and select your sex from the available options. Include your full name, address, city, state, and ZIP code as appropriate.
5. Provide your home and work phone numbers in the designated fields.
6. For health coverage, choose whether you are declining coverage, enrolling for the first time, or canceling existing coverage. Select the appropriate health plan and coverage type (individual or family).
7. List all family members, including dependents, who will be covered under your health plan. Ensure to provide Social Security numbers and exact dates of birth for each person listed.
8. If applicable, fill in the spouse or former spouse information, including employment status and details related to any existing health insurance coverage.
9. Sign the form to authorize any necessary deductions from your payroll or pension check as it relates to your selected coverage.
10. Review all entered information for accuracy. Once complete, save the changes, and choose to download, print, or share the form as required.

Complete your Initial Enrollment Form online today to secure your health coverage.