Application for Elective Coverage (F213-042-000). Application for Elective Coverage (F213-042-000) 2026

1. Click ‘Get Form’ to open the Application for Elective Coverage in the editor.
2. Begin by selecting your business entity type: Sole Proprietor, Partner, For Profit Corporation, or LLC. Ensure you understand the requirements for each category as outlined in the form.
3. Fill in your business name, contact name, address, UBI, account ID, and phone number. This information is crucial for identification and processing.
4. In the section for exempt corporate officers or members, list each individual’s name, position, duties, social security number, date of birth, and percentage of ownership. Ensure all electing members sign where indicated.
5. Review all entered information carefully to ensure accuracy before submitting. Once completed, save your document and follow the instructions to mail it to the appropriate department.

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