Form ps 503 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out your personal information in the EMPLOYEE INFORMATION section. Enter your Last Name, First Name, Middle Initial, Social Security Number, and Date of Birth. Ensure all details are accurate.
3. Next, provide your contact details including Telephone Numbers and Street Address. Make sure to include City, State, and Zip Code for complete information.
4. Indicate your Marital Status by checking the appropriate box and providing the Marital Status Date if applicable.
5. In the ENTER REQUEST(S) BELOW section, select your desired action such as Request Enrollment or Decline Coverage. If enrolling dependents, complete Section G with their details.
6. If you have previous coverage information, fill out that section accurately to ensure a smooth transition.
7. Finally, review all entered information for accuracy before signing and dating the authorization at the bottom of the form.

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