Selected health plan 2026

1. Click ‘Get Form’ to open the Selected health plan in the editor.
2. Begin by filling out the employer section. Enter the effective date, termination date, group name, and group number accurately.
3. In the employee section, provide your full name, work phone, resident address, home phone, and email address. Ensure all information is printed clearly.
4. Select your status by checking one of the options: Transfer to COBRA, Open enrollment, New employee, Address/name change, or Add/remove dependent(s).
5. Complete any additional fields as required for dependents or qualifying events. Make sure to sign and date the form at the bottom.

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