450 Riverchase Parkway East P 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Employee Information' section. Ensure you provide your health group number, health division number, last name, first name, and social security number. All fields marked with an asterisk (*) are required.
3. Next, complete your home mailing address, including city, state, and zip code. Don’t forget to include your primary telephone number and email address if applicable.
4. In the 'Dependent Information' section, list all eligible dependents under this contract. Provide their names, relationships, genders, and social security numbers as required.
5. Select the type of health and dental coverage you are applying for—individual or family—and ensure all necessary details are filled in accurately.
6. Finally, review your application for completeness before signing at the bottom. Make sure to date your signature appropriately.

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