Visit us at humana or humanadental 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the proposed effective date and your company name, city, and state in the designated fields. Ensure all information is printed clearly.
3. Fill out the Enrollment Information section by selecting the relationship of each dependent and providing their height, weight, and gender. Use the appropriate circles for clarity.
4. Complete the Employee Information section with your hours worked per week, SSN, street address, phone number, email address, and language preference.
5. In the Coverage sections (Medical, Dental, Vision), select your desired coverage type and provide any prior coverage details if applicable.
6. Review the Evidence of Health Status section carefully. Answer all questions truthfully regarding current treatments or medical history.
7. Finally, sign and date the agreement section to confirm that all information provided is accurate before submitting your form.

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