01. Edit your form online
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To speed enrollment process, please be thorough and fill out all sections that apply 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin with Section A: Employee Information. Fill in your first name, middle initial, last name, and contact details including street address, city, state, and phone numbers. Ensure your Social Security number or Employee ID is accurate.
- Proceed to Section B: Family Information. List any dependents or domestic partners you wish to enroll or change. Provide their names, Social Security numbers, birthdates, and relationships.
- In Section C: Product Selection, check the coverage types you want (Medical, Dental, Vision) and specify your plan selections if applicable.
- If waiving medical coverage, complete Section E by selecting the reason for waiver and signing where indicated.
- Finally, ensure you sign in Section F confirming the accuracy of your information before submitting the form.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2006 | 4.8 Satisfied (144 Votes) |
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