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How to use or fill out Enrollment Change of Status Waiver Form with DocHub
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Click ‘Get Form’ to open the Enrollment Change of Status Waiver Form in our editor.
Begin by filling out the Group Information section. Enter your employer group name, group number, requested effective date, and other relevant details.
Proceed to Section 1 for Employee Information. Fill in your personal details including name, date of birth, social security number, and contact information.
In Section 2, provide information about any dependents you wish to enroll or waive coverage for. Ensure all fields are completed accurately.
Complete Section 3 regarding additional coverage. Indicate if you or your family members have other insurance and provide necessary details.
If applicable, fill out Section 4 for Waiver of Coverage. List all eligible members who will not be enrolling and their respective coverage details.
Review all entered information for accuracy before signing and dating the form at the end.
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Please complete all information on this form. This information is required to process your enrollment. EMPLOYER GROUP NAME. GROUP NUMBER. REASON FOR STATUS
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