Gov/benefits-by-employer to learn more about choices available to you, view an eLearning and see instructions 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Applicant Information section. Ensure that your name, contact details, and ETF ID are accurate. If there have been any changes, check the appropriate box and provide updated information.
3. If applicable, complete the Spouse Information section if you are adding a spouse or updating their details. Include their name, birth date, and primary care physician.
4. In the Dependent Information section, list any dependents you wish to add or update. Make sure to indicate if any dependents are grandchildren.
5. Select your reason for application in the Eligibility section. This could be due to open enrollment or a life event change. Be sure to provide dates where required.
6. Choose your It’s Your Choice (IYC) Plan Design based on your preferences for coverage levels and monthly payments.
7. Complete any additional sections as necessary based on your specific situation, such as Medicare coverage or removing dependents.
8. Finally, review all information for accuracy before signing and dating the application at the end of the form.

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