Colorado uniform employee application for small group health benefit plans: Fill out & sign online

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Click ‘Get Form’ to open the uniform employee application in the editor.
Begin by filling out the 'Coverage Information' section. Select the appropriate application type: New Coverage, Change/Modification, Open Enrollment, or Special Enrollment.
In the 'Employer Information' section, enter your name, employer's name, proposed effective date, and group number if known.
Proceed to the 'Employee Information' section. Fill in your personal details including first name, last name, social security number, date of birth, and contact information. Ensure all fields are completed accurately.
Complete the 'Type of Health Coverage' section by selecting whether you are applying for Employee Only or Employee & Family coverage.
If applicable, provide information regarding tobacco use and any waivers of coverage in their respective sections.
Review all entered information for accuracy before signing and dating the application at the end.

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