Section A: Enrollee Information (all fields are required) 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Employer Name in the designated field. Ensure that this is accurate as it is essential for processing your application.
3. Fill in your Home Address, including City, State, and ZIP code. This information is crucial for correspondence and verification purposes.
4. Provide your Social Security Number, First Name, Middle Initial (MI), and Last Name. Double-check these entries for accuracy.
5. Enter your Primary and Secondary Telephone Numbers along with your Personal Email Address to facilitate communication regarding your application.
6. Select your Marital Status by checking either 'Single' or 'Married'.
7. Indicate your Gender by selecting 'Male' or 'Female'.
8. Input your Date of Birth in the format mm/dd/yyyy to ensure proper identification.
9. Answer whether you were a full-time employee of a covered entity under the Plan prior to 1/1/2006 by selecting 'Yes' or 'No'. If applicable, provide details of your previous employer.
10. If married, indicate if your spouse is a Plan participant and provide their name and Social Security Number if applicable.

Start filling out Section A today using our platform for free and streamline your application process!