Nebraska health application 2026

1. Click ‘Get Form’ to open the Nebraska Health Application in the editor.
2. Begin by filling out the Employer Data section. Enter your company's name, group number, phone number, and address details accurately.
3. Proceed to the Employee Data section. Fill in the employee's name, social security number, contact information, and employment details including job title and date of hire.
4. In the Waiver of Coverage section, indicate if any coverage is being declined and provide reasons if applicable.
5. Select the desired coverage options under Coverage Selected. Make sure to check all relevant boxes for medical, dental, life, vision, or disability coverage.
6. Complete the Dependent Data section by entering information for each dependent including their names, birth dates, and social security numbers.
7. Answer all health information questions thoroughly in Sections 1 and 2. Provide additional details in Section 3 if necessary.
8. Finally, review your entries for accuracy before signing and dating the Authorization and Certification section at the end of the form.

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