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- Click ‘Get Form’ to open it in the editor.
- 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.
- In Section 4, specify any dependents you are adding or removing. Ensure you provide their names and relationships accurately.
- If applicable, complete Section 5 regarding other coverage information. This is crucial for determining eligibility and benefits.
- Review the acknowledgment section in Section 6. Sign and date the form to certify that all provided information is accurate.
- Once completed, submit the form along with any required documents to the Administrative Office as indicated on the last page.
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