Group-insuranceinc assetsfilesEmployee Enrollment Change Form - Group Insurance Inc 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Employer Information section. Enter the Group Name, CoPower ID#, Contact Person, Email, and Phone Number accurately.
3. Next, move to the Member Information section. Provide details such as Last Name, First Name, Social Security Number, Date of Birth, and Gender. Ensure that all fields are completed for accurate processing.
4. Fill in the Effective Date and Date of Hire. Select your desired plans for Dental and Vision from the options provided.
5. Indicate any changes or reasons for enrollment by checking the appropriate box under 'Reason for Enrollment or Change'.
6. If applicable, list Dependents to be Enrolled or Terminated with their respective details including names and dates of birth.
7. Finally, sign and date the form at the bottom before submitting it to ensure your changes are processed promptly.

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