Get Wellmark N-5408 - Group Application 2015-2025
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Wellmark N-5408 - Group Application online
Completing the Wellmark N-5408 - Group Application online can streamline the process of obtaining health insurance coverage. This guide provides step-by-step instructions to ensure you accurately fill out the form, facilitating your enrollment.
Follow the steps to successfully complete the application
- Click ‘Get Form’ button to obtain the form and open it in the designated editor. This action allows you to start filling out the application thoroughly.
- Begin by entering the employer information in section A. Fill in fields such as Group/Billing Unit No., Department No., Effective Date, Employer Name, and address details including City, State, and ZIP Code.
- Proceed to section B for employee information. Input the first name, middle initial, last name, address, phone numbers, email address (optional), date of birth, and Social Security Number or Tax Identification Number, ensuring accuracy.
- Indicate the gender and status of the employee by checking the appropriate boxes. Fill in the date of hire and select the employment status from options such as full-time or part-time.
- In the health coverage section, select the type of coverage required by marking the appropriate choices, and specify the Health Plan Code and Deductible Amount.
- If applicable, complete section C for enrollment reasons, indicating events such as birth, marriage, or loss of coverage, and provide the relevant date.
- Fill in section D by listing covered family members, ensuring to provide required information for each individual, including Social Security Number and date of birth.
- In section E, answer questions related to Medicare coverage concerning the employee and dependents, filling in details as required.
- Proceed to section F to declare any other health coverage in conjunction with Wellmark, completing required fields about other plans if necessary.
- If waiving health benefits, complete section G, providing the reason for the waiver as specified.
- In section H, review the important information regarding waiver of enrollment, ensuring you understand the implications of declining coverage.
- Finally, complete section I, authorizing and certifying the application. Sign and date the form at the end, confirming the accuracy of the provided information.
- Once you have filled out all sections, save your changes, download a copy, print the form, or share it as needed to ensure timely submission.
Start filling out your Wellmark N-5408 - Group Application online today to secure your health insurance coverage.
A Wellmark ID is a personal identification number issued to you when you enroll in a Wellmark policy, like the N-5408 - Group Application. This ID is essential for accessing your healthcare services, filing claims, and receiving benefits. It is generally found on your insurance card, and knowing it can help simplify your interactions with healthcare providers. Keeping it handy is a good practice.
Industry-leading security and compliance
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.