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The document is a Member Change Form used for updating employee or contract holder information related to health insurance coverage. It includes sections for personal details, reasons for changes (such as adding or canceling dependents), and other modifications like name or address changes. The form requires specific information about dependents, including their relationship to the contract holder and health insurance selections. Additionally, it outlines the process for submitting the form and emphasizes the importance of accurate information.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your Employee/Contract Holder Information. Fill in the Effective Date, Employer/Group Name, and Group Number accurately.
Select the reason for completion from the options provided, such as 'Cancel Entire Contract' or 'Dependent Changes'.
For dependent changes, indicate any additions due to life events like birth or marriage. Provide the date of the event and attach necessary documents if required.
Complete sections for canceling dependents due to divorce or death, ensuring you provide dates and reasons as needed.
Fill out personal details including your name, address, date of birth, and contact information. Ensure all fields are completed in blue or black ink.
If applicable, provide information about other health insurance coverage and Medicare eligibility for yourself and dependents.
Finally, review all entries for accuracy before signing and dating the form at the bottom. Submit via fax or mail as instructed.

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