Ohio Employee Enrollment/Change Form - 51-100 Eligible ... - Aetna 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Company Name and Effective Date at the top of the form. Ensure accuracy as this information is crucial for processing.
3. Select the appropriate option under 'New Hire', 'Rehire/Reinstatement', or other categories, depending on your situation.
4. In Section A, Coverage Selection, clearly check the boxes for Medical, Dental, and Life/Disability coverage options you wish to enroll in. Use black ink for clarity.
5. Complete Section B with your personal information including Member Aetna ID Number (if available), Last Name, First Name, and contact details.
6. In Section C, list all individuals you are enrolling or changing coverage for. Be sure to indicate if you are adding or removing dependents.
7. Review Sections D through I carefully, providing any necessary Medicare information and completing the Health Questionnaire if applicable.
8. Finally, sign and date the form in Section H to certify that all information is accurate before submitting it to your employer.

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