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Begin by filling out the Enrollee Information section. Clearly print your name, address, phone number, and other personal details as required.
Indicate your marital status by selecting either 'Single' or 'Married'. Provide your date of birth and gender.
Complete the Enrollee and Dependent Information section if applicable. List all dependents, including their names, dates of birth, and social security numbers.
In the Medical History section, answer all questions truthfully regarding any past medical conditions. Use the provided checkboxes for clarity.
Review the Prior Medical Coverage Information section carefully. Fill in details about any previous insurance coverage you or your dependents may have had.
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