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Employee Enrollment Form Nationwide Life Insurance Company - iu17

Employee Enrollment Form Nationwide Life Insurance Company - iu17 2025

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The document is an Employee Enrollment Form for Nationwide Life Insurance Company, detailing the information required from both employers and employees for insurance coverage enrollment. It includes sections for employer and employee details, coverage elections, waivers, beneficiary information, and important notices regarding late enrollment and fraudulent claims. The form aims to facilitate the selection of various insurance benefits while ensuring compliance with legal requirements.

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Click ‘Get Form’ to open the Employee Enrollment Form in the editor.
Begin with Section I, where you will enter your Employer Information. Fill in the Group Number, Employer Name, and Address details accurately.
Proceed to Section II for Employee Information. Complete all fields including your name, contact information, marital status, and Social Security number.
In Section III, indicate your coverage elections by checking the appropriate boxes for yourself and any dependents. Ensure you understand the coverage options available.
If you choose to waive coverage, complete the waiver section in Section IV. Provide a reason for declining if applicable.
Finally, review all sections for accuracy before signing and dating the form in Section VI. This confirms that all information is correct.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is a benefits enrollment form?

Benefits enrollment, also known as open enrollment or benefits election, refers to the process through which employees choose and sign up for the employee benefits offered by their employer. These benefits often include health insurance, dental insurance, vision insurance, life insurance, retirement plans, and similar.

How do I cancel my Nationwide life insurance policy?

Need to cancel a policy Contact your agent or call 1-800-848-6331 to cancel. Were unable to cancel by email or online.

What is the purpose of an enrollment form?

Enrollment forms record whether employees have enrolled in or waived group benefits. For instance, if you have more than 50 full-time employees, you will need this data to complete IRS forms 1094 and 1095, which record health care coverage.

What is members life insurance company?

MEMBERS Life Insurance Company operates as an insurance company. The Company offers life, accident, and health insurance throughout the United States.

How do I contact nationwide life insurance?

Want help navigating life insurance? Talk with one of our life insurance specialists today. Call 1-866-207-9160 or schedule a call.

What is an employee form?

New employee forms are documents an onboarding employee completes for a company. Some forms are required by law, such as tax forms, while others may be for a particular company or position. They help verify the new employee understands company policies, compensation payments and benefits.

What happens if an employee misses open enrollment?

Legally, employers are not required to do anything for employees who have missed the open enrollment deadline. In fact, the terms of your benefits plans may prohibit you from making exceptions for employees who do not make benefits elections within a certain time period, such as before the new plan year begins.

Employee Enrollment Form Nationwide Life Insurance Company - iu17 2025

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