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1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out your personal information in Section 3. Include your first name, last name, social security number, date of birth, and contact details.
3. In Section 4, specify any dependents you are adding or removing. Ensure you provide their names and relationships accurately.
4. If applicable, complete Section 5 regarding other coverage information. This is crucial for determining eligibility and benefits.
5. Review the acknowledgment section in Section 6. Sign and date the form to certify that all provided information is accurate.
6. Once completed, submit the form along with any required documents to the Administrative Office as indicated on the last page.

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