HOW TO COMPLETE YOUR A HIGHMARK COMPANY An Independent 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Employer Name and Telephone Number in the designated fields.
3. If you are making changes, check the 'Change' box and proceed to fill out the Association Name if applicable.
4. Input the Group Number, Employee's name (Last, First, Middle Initial), and Member Identification Number.
5. Select all applicable changes under 'Change to Member Records', 'Change Contract Type', and 'Change Enrollment Status'.
6. Provide a brief description of the changes in the specified field for clarity.
7. Complete address details only if changing address or phone numbers. Fill in all relevant fields for Employee/Contract Holder, Spouse/Domestic Partner, and Dependents as necessary.
8. Finally, ensure both employee and employer sign and date the form before submission.

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