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CC-053 (3-14) CC-053 3/28/14 8:03 AM Page 1 SPECIAL ENROLLMENT PERIOD FORM A Special Enrollment Period is DE? Ned as a time outside the open enrollment period during which you and your family have

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What is special enrollment period form?

Special enrollment period form is a form that allows individuals to enroll in a health insurance plan outside of the regular open enrollment period.

Who is required to file special enrollment period form?

Individuals who experience certain qualifying life events such as getting married, having a baby, or losing other health coverage are required to file a special enrollment period form.

How to fill out special enrollment period form?

To fill out a special enrollment period form, individuals must provide information about the qualifying life event that makes them eligible for special enrollment and submit the form to their health insurance provider or the healthcare marketplace.

What is the purpose of special enrollment period form?

The purpose of the special enrollment period form is to allow individuals to sign up for health insurance coverage when they experience a qualifying life event outside of the regular open enrollment period.

What information must be reported on special enrollment period form?

Information such as the qualifying life event, the date of the event, and any other relevant details must be reported on the special enrollment period form.

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