GROUP ENROLLMENT FORM DO NOT USE - INTERNAL 2026

1. Click ‘Get Form’ to open the GROUP ENROLLMENT FORM in the editor.
2. Begin with the 'Group Employer Information' section. Ensure that the Group Benefits Administrator fills this out completely, including Subscriber Status and Group Number. Use blue or black ink and print clearly.
3. Proceed to the 'Subscriber Plan' section. Here, check the applicable plan(s) and coverage type for yourself and any dependents. Make sure to indicate your selection clearly.
4. In the 'Reason for Enrollment/Change' section, select the appropriate reason for your enrollment or change. This could include options like New Hire or Loss of Coverage.
5. Complete the 'Subscriber Information' section by providing personal details such as name, contact information, and primary care physician details. Remember to sign and date at the end of this section.
6. If applicable, fill out sections for additional dependents by providing their information as required in each field.

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