DRAFT2019LHPEmployeeHealthApplication(100118)c.docx 2026

1. Click ‘Get Form’ to open the DRAFT2019LHPEmployeeHealthApplication(100118)c.docx in the editor.
2. Begin with SECTION 1: EMPLOYER INFORMATION. Fill in your employer's name, hire date, and address details including street, city, state, and zip code.
3. Move to SECTION 2: EMPLOYEE INFORMATION. Enter your full name, birth date, social security number, marital status, gender, contact numbers, email address, job title, and hours worked per week.
4. In SECTION 3: OTHER INSURANCE COVERAGE, indicate if you or any dependents are disabled and provide details about any other health insurance coverage.
5. Complete SECTION 4: DEPENDENT INFORMATION for all participating dependents by providing their names, relationships, social security numbers, dates of birth, ages, genders, and tobacco use status.
6. In SECTION 5: HEALTH PLAN PARTICIPATION, select your coverage preference and reason for decline if applicable.
7. SECTION 6: HEALTH INFORMATION requires you to answer health-related questions regarding yourself and your dependents. Provide height and weight as well as any medical conditions or treatments experienced in the past five years.
8. Finally, review SECTION 7: AGREEMENTS AND AUTHORIZATION. Ensure all information is accurate before signing and dating the application.

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