Luzerne County Health Insurance Form 2025

1. Click ‘Get Form’ to open the Luzerne County Health Insurance Form in the editor.
2. Begin by entering your last name, first name, and middle initial in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill in your address details including street, city, state (PA), and zip code. This helps in establishing your residency for insurance purposes.
4. Provide your Social Security number (SS#), date of birth, hire date, marital status, and sex. Select your marital status from the options provided: single, married, separated, divorced, or widowed.
5. List your home phone number and department. If applicable, include union information.
6. For dependents under age 23, enter their names and details including SS#, date of birth, and whether they are full-time college students.
7. Indicate your primary care physician's name for you and each family member listed on the form.
8. Select the insurance plan you wish to be covered under by checking the appropriate box for First Priority or Geisinger. Choose between individual or family coverage as well as dental options.
9. Finally, sign and date the form at the bottom to confirm that all information is accurate before submitting it.

Start filling out your Luzerne County Health Insurance Form online for free today!