Get the free Univera Active enrollment form.pdf - Tompkins Insurance

ActiveUnivera GROUP ENROLLMENT FORM DO NOT USE INTERNAL PURPOSES ONLY P.O. Box 23000, Rochester, NY 14692 Instructions on last page. All Dates mm/dd/by PLEASE PRINT CLEARLY 1 ? Group Employer Information

How to fill out univera active enrollment formpdf

How to fill out Univera Active Enrollment FormPDF:

1. Start by downloading the Univera Active Enrollment FormPDF from the official Univera website.
2. Open the downloaded form using a PDF viewer on your device.
3. Begin by providing your personal information such as your name, date of birth, and contact details in the designated fields.
4. Fill in your address, including street name, city, state, and zip code.
5. Indicate your preferred language for communication and specify if you need any special accommodations.
6. Mention your Social Security number and identify if you are the primary policyholder or a dependent.
7. If you are a dependent, provide the name and information of the primary policyholder.
8. Choose the type of plan you want to enroll in, such as individual or family coverage, and select the appropriate options.
9. If you are already a Univera member, provide your current membership ID and group number.
10. Enter the date on which you want your coverage to start.
11. If you have any other insurance coverage, indicate it in the form and mention if it is through your employer.
12. If applicable, provide details of any additional family members you wish to enroll and indicate their relationship to you.
13. Review the form for accuracy and completeness, ensuring that all required fields are filled.
14. Sign and date the Univera Active Enrollment FormPDF to complete the process.
15. Submit the form as instructed, either by mailing it or submitting it online, depending on the specified method.

Who needs the Univera Active Enrollment FormPDF:

1. Individuals who want to enroll in a Univera healthcare plan need the form to provide their personal and insurance information.
2. Dependents who are eligible for coverage under an existing Univera policy also need to fill out the form.
3. Employees who are offered Univera health insurance through their employer may need to complete the form during the open enrollment period or when experiencing a qualifying life event.

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