Health Insurance Enrollment Form - University of Utah - hr utah 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Employee Name and Employee ID # in the designated fields. Ensure that all personal information is accurate.
3. Fill out your Address, City, State, Zip Code, Email Address, Home Phone, and Work Phone. This information is crucial for communication regarding your enrollment.
4. Select your desired Coverage Level by checking either 'Employee Only' or 'Family Coverage'. Then, specify the Coverage Amount in $10,000 increments between $10,000 and $500,000.
5. Designate your Primary and Contingent Beneficiaries along with their relationship to you. If necessary, attach a separate sheet for additional beneficiaries.
6. Review the Certification section carefully. Sign and date the form to confirm that all provided information is true and correct before submission.

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