Employee enrollment form 2025

1. Click ‘Get Form’ to open the employee enrollment form in the editor.
2. Begin by filling out the 'Group' section, including your name, requested effective date of coverage, and group name or policy number.
3. In the 'Reason for Application' section, select the appropriate option that applies to your situation, such as 'New Hire' or 'Life Event'.
4. Complete Section A with your personal information: last name, first name, address, date of birth, sex, marital status, and contact details.
5. In Section B, list all enrolling dependents. Ensure you provide their names, relationships, and relevant health information.
6. Proceed to Section C to select your desired coverage options for medical, dental, and vision plans. Indicate any additional benefits you wish to enroll in.
7. Fill out Sections D and E regarding prior medical insurance information and other medical coverage details if applicable.
8. Finally, review all sections for accuracy before signing in Section H to authorize the submission of your application.

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