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- In Part A, enter your last name, first name, and middle initial. Provide your Social Security Number and date of birth in the specified format.
- Fill in your home mailing address and indicate your sex and marital status by placing an 'X' in the appropriate boxes.
- Provide a daytime telephone number where you can be reached during business hours.
- In Part B, select the health benefits plan you wish to enroll in by entering the plan name and enrollment code from the brochure.
- If enrolling for Self and Family, complete items 2a through 2f with family members' details including names, dates of birth, and relationship codes.
- Complete Part G by signing and dating the form. Ensure all information is accurate before submission.
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