Application for Change - Western Financial Group Insurance Solutions 2026

1. Click ‘Get Form’ to open the Application for Change in our editor.
2. Begin by filling out the Plan Member Information section. Enter your name and municipality name accurately.
3. If applicable, indicate the reason for termination of coverage and provide the date you last worked.
4. For name changes, input your previous name and your new name. Remember, this request must be completed within 31 days of marriage or divorce.
5. If changing coverage designation, select whether it’s a change to family or single coverage. Complete the relevant sections based on your situation, including spouse details and dependent child information.
6. In the Certification and Authorization section, review all statements for accuracy before signing. Ensure you understand how your personal information will be handled.
7. Finally, add the employer's signature and date signed before submitting the form to Western Financial Group Insurance Solutions.

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