202 Employee Health Application for Employers Group ... 2025

1. Click ‘Get Form’ to open the 202 Employee Health Application in the editor.
2. Begin by filling out Section 1: Employer Information. Enter the employer's name, street address, city, state, and zip code.
3. Proceed to Section 2: Employee Information. Input the employee's full name, hire date, address, 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 your dependents are on COBRA or have other health insurance. Provide details if applicable.
5. Complete Section 4: Dependent Information for all participating dependents. Include their names, relationships, social security numbers (if enrolling), dates of birth, ages, genders, and tobacco use status.
6. In Section 5: Health Plan Participation, select your coverage preference and provide a reason for declining if applicable.
7. Fill out Section 6: Health Information by answering health-related questions and providing necessary details about medications taken in the last year.
8. Review Sections 7 through 9 for agreements and authorizations. Ensure all signatures are completed before submitting the application.

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