After completing the following section, please forward this form along with the enclosed envelope to 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Subscriber’s Name, including Last, First, and Middle Initial in the designated fields.
3. Fill in your Identification Number and Home Address, ensuring all details are accurate for proper processing.
4. Provide the Group Name and Group Number as required.
5. Enter the Dependent’s Name and Birth Date. This information is crucial for identifying the dependent.
6. Indicate whether the dependent resides in your home by selecting 'Yes' or 'No'.
7. Answer if the dependent is more than 50% financially dependent on you for support.
8. Complete employment-related questions regarding whether the dependent is employed, their date of hire, hours worked per week, and nature of duties.
9. Finally, certify that all provided information is correct by signing and dating the form before forwarding it to your physician.

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