50625 1008r form 2025

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4 out of 5

37 votes

The document is a Group Member Life & Dental Enrollment Application that collects information from employees regarding their enrollment in various insurance coverages, including dental, life, accidental death and dismemberment (AD&D), and disability. It includes sections for employer and employee details, coverage selections, beneficiary information, and acceptance or refusal of coverage. The application emphasizes the importance of accurate information for processing claims and outlines the responsibilities of both the employee and employer.

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Click ‘Get Form’ to open the 50625 1008r form in the editor.
Begin with Section A, where you will enter employer-provided information such as Group Name, Coverage Effective Date, and Date of Hire. Ensure all fields are filled accurately.
Move to Section B for Employee Information. Fill in your Last Name, First Name, Gender, Date of Birth, and contact details. Make sure to provide your Social Security number for identification.
In Section C, select your Dental Coverage options. Indicate whether you want coverage for yourself, spouse, or children by checking 'Yes' or 'No'.
Proceed to Section D for Life and Disability Coverage Selection. Again, indicate your choices clearly and provide any necessary details regarding voluntary coverages.
Complete Sections E and F by providing additional employee and dependent information as required. Attach separate sheets if needed.
Finally, review Sections G through I for acceptance of coverage and sign where indicated to finalize your application.

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Versions	Form popularity	Fillable & printable
2016	4.2 Satisfied (55 Votes)
2008	4 Satisfied (37 Votes)

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