Humana enrollment form pdf 2026

1. Click ‘Get Form’ to open the Humana Enrollment Form PDF in the editor.
2. Begin by filling in your Current Medical and Dental Group numbers, along with your Benefit number and Class/Division. Ensure that you enter the Proposed Effective Date for changes accurately.
3. In the Employee Information section, provide your Last Name, First Name, Middle Initial, and Social Security Number. Indicate any changes to your Medical or Dental benefits by selecting the appropriate options and entering new Benefit numbers if applicable.
4. For dependent changes, complete the Dependent Changes section by providing each dependent's Last Name, First Name, Social Security Number, Gender, Date of Birth, and Relationship. Specify whether you are adding or deleting dependents from your current plan.
5. Finally, sign and date the form at the bottom. If a legal representative is signing on your behalf, include their name and relationship.

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