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Click ‘Get Form’ to open gp55229 in the editor.
Begin by filling out your personal information in the Employee Information section. Enter your name, social security number, mailing address, birth date, and gender. Ensure all details are accurate.
Next, provide your employment details including the date employed full-time, job occupation/class, and hours worked per week. This information is crucial for determining eligibility.
If applicable, complete the Eligible Dependent Information section by listing dependents you wish to enroll. Include their names, birth dates, genders, and relationships to you.
In the Coverage section, indicate your choices for dental, vision, life insurance, and disability coverage by selecting 'Elect' or 'Decline' as appropriate.
Finally, read through the Employee Agreement carefully before signing and dating the form at the bottom. Ensure you understand all statements regarding coverage eligibility.

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