Section 1 is to be completed by the employer and Section 2 is to be completed by the employee. The Employee Name and Social Security number must be completed for all transactions.
Additional Instructions for New Enrollments
Employer – Complete the first four lines in Section 1.
Employee – To enroll, complete Section 2 in full and sign the Accepting Coverage section after reading the statement below. To decline, sign the Declining Coverage section after reading the statement below.
Additional Instructions for Changes
Employer – Complete the Change in Section 1 including the date of the qualifying event and the nature of change.
Employee – Complete only the information which has changed. For example, to report a marriage and add a spouse, complete the Marital Status, Coverage Elected for spouse, Spouse Name, Social Security Number, Sex, Birth Date, Employer Information and if the spouse has other coverage and Medicare eligibility. Sign the Accepting Coverage section. For a change of address, complete the new address and sign the Accepting Coverage
Additional Instructions for Terminations
Employer – Complete the Termination box in Section 1 including the Date of Termination and Effective Date.