Form online 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information in the designated fields, including your name, member ID or SSN, and phone number. Ensure that all details are accurate for processing.
3. In Section I, check the boxes for the insurance plans you wish to enroll in. Specify who you want to enroll (yourself, spouse, or children) and indicate the desired effective date of coverage.
4. Complete the information about yourself and any dependents you wish to enroll. Provide necessary proofs as required for each dependent.
5. If applicable, fill out Section II to cancel any existing insurance coverage by providing names and qualifying events.
6. For name or address changes, complete Section III with your new details and attach legal documentation if necessary.
7. Finally, sign Section IV to certify that all information is correct before submitting your completed form back through our platform.

Start filling out your form online today for free and streamline your insurance enrollment process!