Active employee notice of election (noe) - Orangeburg County 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out your personal information in the ENROLLEE INFO section, including your Social Security Number, last name, first name, and date of birth.
3. Select the type of change you are making: New Hire, Transfer, or Change. Ensure to indicate any relevant dates such as Date of Change Event and Effective Date.
4. Complete the MEDICARE section if applicable by listing yourself and any dependents eligible for Medicare.
5. In the HEALTH PLAN section, select one plan and one level of coverage. Remember that alterations like mark-throughs are not allowed.
6. Fill out the DEPENDENTS section carefully. List all eligible dependents who will be covered under your selected plans.
7. Finally, review the CERTIFICATION & AUTHORIZATION section. Sign and date the form to confirm accuracy before submission.

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