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- Begin by filling out Step 1, which requires personal information. Enter your first name, middle name, last name, and suffix. Provide your home address, city, state, ZIP code, and county.
- Proceed to Step 2 to include details about your family members. List all individuals living with you who need coverage. Ensure you provide their names and relationships accurately.
- In Step 3, indicate if any family member is Native American Indian or Alaska Native. If yes, complete Appendix B for additional benefits.
- Complete the income section for each family member needing coverage in Step 4. Include employer information and income details as required.
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- Finally, mail your completed application to the provided address on page 7 of the form.
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