290-4397 SB EESHT 10 OH 6 10-2026

1. Click ‘Get Form’ to open the Employee Enrollment Form in the editor.
2. Begin by completing the 'Employee Information' section. Fill in your name, address, social security number, and contact details accurately.
3. In the 'Group' section, indicate the requested effective date of coverage and reason for application. Choose from options like New Hire or Life Event.
4. Proceed to 'Family Information' where you will list all dependents enrolling. Ensure to include their names, birthdates, and relationships.
5. In 'Product Selection', check the boxes for medical, dental, and vision coverages you are enrolling in. Specify any additional life insurance amounts if applicable.
6. Complete the 'Prior Medical Insurance Information' section if applicable. Provide details about any previous coverage.
7. Answer all questions in the 'Medical History' section truthfully to avoid issues with your coverage.
8. Finally, review your entries for accuracy before signing at the end of the form to authorize your selections.

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