Ga 51340 pp 2026

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264 votes

The document is a Group Employee and Individual Application and Enrollment Form for Humana, intended for employers with 1-100 employees in Illinois. It outlines the process for enrolling in various health insurance plans, including HMO, PPO, dental, vision, life, and disability coverage. The form requires detailed personal information from applicants, including qualifying events for enrollment, prior coverage details, and health history. It also includes sections for waiving coverage and authorizations related to medical records.

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Click ‘Get Form’ to open the ga 51340 pp in the editor.
Begin by entering the proposed effective date and employer/group name in the designated fields. Ensure all information is printed clearly.
Select the qualifying event from the options provided, such as 'New business enrollment' or 'Open Enrollment event'. Fill in the date of the qualifying event accurately.
In the Enrollment Information section, list all dependents including their names, genders, and social security numbers. Use checkboxes for relationship status.
Complete the Employment Status section by indicating hours worked per week and providing your occupation and annual salary.
For prior coverage details, answer questions regarding previous medical and dental insurance. Be sure to provide policy numbers where applicable.
Review all entered information for accuracy before submitting. Utilize our platform's features to save your progress or share it with others for review.

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Versions	Form popularity	Fillable & printable
2014	4.9 Satisfied (264 Votes)

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