Florida fl72000 2026

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The document is a Small Group Employee and Individual Application and Enrollment Form for Humana, specifically designed for businesses with 1-50 employees in Florida. It outlines the necessary information required for enrollment in various health insurance plans offered by Humana, including PPO, EPO, HMO, and dental plans. The form includes sections for personal details, qualifying events for enrollment, beneficiary information, and agreements regarding coverage. It emphasizes the importance of providing accurate information and the consequences of fraud or misrepresentation.

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Click ‘Get Form’ to open the Florida FL72000 in the editor.
Begin by entering the proposed effective date at the top of the form. Ensure you format it as MM/DD/YYYY.
Fill in your employer or group name and city, followed by selecting the qualifying event from the provided options.
In the enrollment information section, provide details such as your last name, first name, middle initial, and social security number.
Indicate your language preference and complete personal information including date of birth, gender, and contact details.
If applicable, fill out beneficiary information for life and disability benefits. Make sure to include names and relationships.
Review the agreement section carefully. Sign and date where indicated to confirm your understanding and acceptance of terms.

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Versions	Form popularity	Fillable & printable
2015	4.8 Satisfied (50 Votes)
2013	4.3 Satisfied (150 Votes)
2013	4.4 Satisfied (40 Votes)
2009	4.3 Satisfied (38 Votes)
2008	4.3 Satisfied (48 Votes)

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Florida fl72000 2026

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