Employee Enrollment Application: Group Size 51+ Eligible 2026

1. Click ‘Get Form’ to open the Employee Enrollment Application in the editor.
2. Begin with Section 1, where you will enter your employer's name, address, group number, and requested effective date. Ensure all fields are filled accurately.
3. In Section 2, select the reason for application. Options include new enrollment or adding a dependent. If applicable, fill in details for any qualifying events.
4. Proceed to Section 3 if you selected 'Add dependent' in Section 2. Fill in the event date and type of status change.
5. In Section 4, choose your desired plan types for medical, dental, and vision coverage. Indicate whether you want coverage for yourself only or additional dependents.
6. Complete Sections 5 and 6 with employee and family information respectively. Be sure to provide accurate Social Security numbers as required.
7. Review Sections 7 through 11 carefully before signing in Section 10. Ensure all information is correct and complete any necessary waivers.

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