19 2 Group Life Cycles and Member Roles - Publishing Services 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section A, where you will enter the Employer Provided Information. Fill in the Group Name, Coverage Effective Date, Life Group Number, Date of Hire, Occupation, Work Status, County, and Annual Salary.
3. Proceed to Section B for Employee Information. Clearly write your Last Name, First Name, Social Security Number, Address, Gender, Date of Birth, Email Address, and Phone Numbers.
4. In Section C, select your Dental Coverage options. Indicate whether you want coverage for yourself and any dependents by checking 'Yes' or 'No'.
5. Section D requires you to add dependent information. Include their names, Social Security Numbers, relationship to you, and dates of birth.
6. Complete Section E by providing details about any other dental insurance you or your dependents may have.
7. In Section F, choose your Life and Disability Coverage options. Again indicate if you want coverage for yourself and dependents.
8. Finally, review Sections G through I for acceptance of coverage and sign where indicated to complete your application.

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