Employee Enrollment Application Wisconsin 2025

1. Click ‘Get Form’ to open the Employee Enrollment Application Wisconsin in the editor.
2. Begin with Section A: Employee Information. Fill in your last name, first name, middle initial, and Social Security number. Ensure your home address, phone numbers, and email are accurate.
3. In Section B: Application Type, select the appropriate enrollment type such as 'New enrollment' or 'Open enrollment'.
4. Proceed to Section C: Type of Coverage. Choose your desired medical, dental, and vision coverage options by selecting from the provided choices.
5. Complete Section D: Coverage Information by listing all eligible dependents and their details including names, birthdates, and relationships.
6. In Section E: Other Group Coverage, indicate if you or any dependents have existing Medicare or other health coverage.
7. If declining coverage for yourself or dependents, fill out Section F with the necessary reasons.
8. Finally, review Section G: Terms, Conditions and Authorizations carefully before signing and dating the application.

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