(Maryland Groups not subject to Small Group Reform) 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out Section I, 'Employer Information.' Enter the employer/group administrator's details, effective date requested, group number, and social security number.
3. Proceed to Section II, 'Enrollee.' Clearly provide your personal information including name, date of birth, occupation, and contact details. Ensure all fields are completed accurately.
4. In Section III, select the type of enrollment by checking either 'New' or 'Coverage Change.'
5. For Section IV, choose your desired type of coverage. Confirm with your employer about available options before making a selection.
6. If applicable, complete Section V for any changes to existing enrollment. List dependents affected and provide necessary dates.
7. Fill out Section VI with dependent information if you have children or a spouse. Include their names and relevant details.
8. Complete Sections VII through XI as required. Ensure you check boxes for Medicare coverage and prior insurance if applicable.
9. Finally, sign and date the form in Section IX to confirm your enrollment and consent to terms.

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