Follow the steps to fill out the form correctly.

1. To start, click the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by entering the customer name in the designated field at the top of the form.
3. Next, input the employee's last name followed by their first name in the specified sections.
4. Fill in the social security number in the provided field, ensuring it is accurate.
5. Enter the employee's date of birth using the month, day, and year format.
6. Indicate the date of hire by filling in the month, day, and year as applicable.
7. Select the marital status by checking the appropriate box: single, married, widowed, or divorced.
8. In the section labeled 'Reason for Refusal,' indicate if you have other group coverage sponsored by your employer or your spouse's employer. Provide any additional reasons in the other section if necessary.
9. Be sure to complete the signature fields. The employee will sign and date the form, followed by a witness signature and date as well.
10. Once all fields are filled out, review the information for accuracy. Afterwards, you can save your changes, download, print, or share the form accordingly.

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