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Get Wellmark N-5408 - For Non-aca Groups 2018-2025
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How to fill out the Wellmark N-5408 - for Non-ACA Groups online
Completing the Wellmark N-5408 - for Non-ACA Groups application online is essential for securing your health insurance coverage. This guide will provide you with clear, step-by-step instructions to fill out the form accurately and efficiently.
Follow the steps to complete the form easily online.
- Use the 'Get Form' button to access the Wellmark N-5408 document and open it in your preferred digital editing platform.
- Begin by filling out Section A, which requires employer information. Provide details including group/billing unit number, department number, effective date, employer name, phone number, and employer address.
- In Section B, enter your personal information as the employee. Include your full name, address, phone numbers, email address, date of birth, marital status, gender, social security number or tax identification number, date of hire, and employment status.
- Section C addresses the waiver of enrollment. Indicate if you are waiving health coverage for yourself and/or your dependents, and select a reason for the waiver.
- For Section D, specify the enrollment reason or event. Select any applicable special enrollment event that applies to you and list the date of this event.
- In Section E, add the names and birth dates of all dependents to be covered. If additional space is needed for more than four dependents, prepare to attach a separate sheet.
- Complete Section F regarding Medicare coverage. Answer yes or no to the questions about Medicare enrollment and provide the necessary details for individuals listed in Section E.
- Section G seeks information about any other health coverage. Indicate whether you or your dependents will keep other coverage and provide the related policy information.
- Review Section H for important information regarding waiver enrollment. Ensure you understand the implications of waiving coverage.
- In Section I, certify that you are authorized to apply for coverage. Provide your signature and the date at the bottom of the form.
- Finally, save your filled form, and choose to download, print, or share it as needed.
Complete your Wellmark N-5408 application online today to ensure you receive your health benefits.
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Blue Shield and Blue Cross are part of the same insurance alliance but operate as separate entities. While they both offer various health plans, including products like the Wellmark N-5408 - for Non-ACA Groups, each typically has its own networks and provider agreements. Make sure to compare your local options to find the best fit for your coverage needs.
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