Form n 5408-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section A, where the employer must provide their information. Fill in the Group/Billing Unit No., Department No., Effective Date, Employer Name, Phone Number, and Address details.
3. Move to Section B for Employee Information. Enter your name, address, phone numbers, email (optional), date of birth, marital status, gender, Social Security Number/Tax Identification Number, and employment status.
4. In Section C, if waiving health benefits, check the appropriate box and provide a reason for waiving coverage.
5. Complete Section D by indicating any special enrollment events that apply to you and listing relevant dates.
6. Fill out Section E with details of all dependents to be covered. Ensure to include their names and dates of birth.
7. Proceed to Sections F and G for Medicare coverage information and other carrier details as required.
8. Finally, review Section I for Authorization and Certification. Sign and date the application before submission.

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