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- Click ‘Get Form’ to open the hc2 form in the editor.
- Begin by entering your Employer Group Name and Case/Cert# at the top of the form. Indicate the reason for the change and requested effective date.
- In the Continuant Information section, clearly print your name, home telephone, work telephone, and address details.
- List yourself and all eligible dependents impacted by the change. Fill in their names, Social Security numbers, and select their sex.
- Select your desired medical coverage level and health plan from the options provided. Ensure you choose one health plan and one benefit.
- Complete the Dental Coverage Level section if applicable, indicating whether you are waiving dental or selecting a coverage option.
- Finally, review the Authorization and Acceptance section. Sign and date where indicated before submitting your application.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2005 | 4.8 Satisfied (32 Votes) |
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