Form online 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section A: Employee Information. Fill in your personal details, including your name, Social Security number, and contact information. If enrolling in a UnitedHealthcare HMO plan, select a Primary Care Physician (PCP) from the Provider Directory.
3. Move to Section B: Dependent Information. Provide details for each dependent, including their names and Social Security numbers. Ensure you select a PCP for each dependent enrolling in an HMO plan.
4. In Section C: Product Selection, check the boxes for the medical and dental plans you are enrolling in. Write down the plan codes or descriptions as required.
5. Complete Section D if applicable by indicating any other medical insurance coverage you or your dependents may have.
6. If waiving coverage, fill out Section E and provide a signature. Review Sections F and G carefully before signing and dating them.

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