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- Indicate your Marital Status by checking the appropriate box. If applicable, specify if you are covered under Medicare.
- In the Request(s) section, select whether you are requesting enrollment for yourself or your family. Choose between Empire Plan or HMO and provide any necessary codes.
- Complete the Dependent Information section if adding or changing dependents. Fill in their names, dates of birth, relationships to you, and check whether you are adding (A), deleting (D), or changing (C) their coverage.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2020 | 4.8 Satisfied (221 Votes) | |
| 2019 | 4.3 Satisfied (52 Votes) | |
| 2017 | 4.2 Satisfied (78 Votes) | |
| 2017 | 4.4 Satisfied (129 Votes) | |
| 2014 | 4.3 Satisfied (76 Votes) | |
| 2011 | 4.8 Satisfied (49 Votes) | |
| 2007 | 4.6 Satisfied (43 Votes) | |
| 2006 | 4 Satisfied (54 Votes) | |
| 2001 | 4.1 Satisfied (28 Votes) |
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