Enrollment, Change and Termination Forms

Submitting incomplete forms causes processing delays. The following tips should help ensure a smooth, automated enrollment process.

• Please complete all applicable fields on the form. Do not line through or use "N/A" in fields that are not applicable. Leave those fields blank.
• Certain fields are required for processing. These are:
  • Group Number
  • Group Name
  • Employee/Dependent Name(s)
  • Date(s) of Birth
  • Social Security Number
  • Gender
  • Coverage Information
• Carefully follow the instructions provided with the form(s).
• Black or blue ink is preferred. Do not use red ink or pencil.
• Clearly print inside individual boxes.
• Use the month, day and full year (for example, 07172001 for July 17, 2001).
• Punctuation marks such as periods, commas, or dollar signs should not be used.
• A dash should only be used in a name if it is actually part of the legal name.
• After completing the form, review it carefully to assure all applicable fields were completed accurately.
• If there are more dependents than are allowed on the form, use another enrollment form. Complete the dependent section only and attach it to the initial form.
• Please do not write notes on the forms. Use a separate sheet of paper to relay any information.