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Employee Enrollment and Change Form - Group Health - producer ghc 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling out the employer section. Enter the original date of hire, coverage effective date, and group name. Ensure all dates are formatted correctly.
- In the employee section, print your name clearly along with your resident address. If your mailing address differs, provide that as well.
- Complete your contact information including work phone, home phone, and email address. Remember that providing your email allows for communication from Group Health.
- Select your health plan and indicate whether you want to add or remove dependents. Fill in their details accurately including relationship to you.
- Finally, sign and date the form at the bottom to confirm all information is correct and complete.
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You have 30 days from your date of hire or qualifying life event to enroll in and/or make changes to your health insurance.
If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.