New Jersey Enrollment Change Request 2026

1. Click ‘Get Form’ to open the New Jersey Enrollment Change Request in our platform's editor.
2. Begin by completing the Employer Group Information section, including the Group Number and Group Name. This is essential for processing your request.
3. In Section A, indicate the Type of Activity by checking the appropriate boxes for adding, changing, or removing coverage. Be sure to include the Date of Event.
4. Fill out Section B with your Employee Information. Ensure all fields are completed clearly, including your contact details and employment information.
5. In Section C, select your Plan Options by checking one box in the left column and indicating your Primary Copay amount.
6. Section D requires you to list individuals covered under your plan. Use 'A', 'C', or 'R' to denote whether you are adding, changing, or removing coverage for each individual.
7. Complete Sections E and F if applicable, providing details about any other insurance coverage and dependent information.
8. Finally, sign in Section G to confirm that all information is accurate. The employer must complete Section H for verification before submission.

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