Get the free Self-Funded Group Enrollment Form - bega-inccomb

Significant Benefit Services, Inc. P.O. Box 7777 Lancaster, PA 176047777 pH: 7175811300 * Fax: 7175811319 New Enrollment Add Dependents Coverage Change Reinstatement Special Enrollment: Refunded Group

How to fill out self-funded group enrollment form

How to fill out a self-funded group enrollment form:

1. Start by carefully reading the instructions or guide provided with the form. This will help you understand the requirements and details needed to complete the form correctly.
2. Begin by filling out the basic information section. This typically includes the name of the group, the employer or organization associated with the group, and relevant contact information.
3. Provide details about the group members. This section may require you to list the names, dates of birth, social security numbers, and relationship to the primary member (e.g., spouse, dependent) for each individual included in the group.
4. Indicate the desired coverage options for the group members. This could include choosing the type of plan (e.g., medical, dental), determining the level of coverage (e.g., single, family), and selecting any additional benefits or add-ons.
5. If there are any specific enrollment periods or deadlines mentioned, make sure to adhere to them. This will ensure that your enrollment is processed in a timely manner.
6. Double-check all the information provided before submitting the form. Review all names, dates, and contact details for accuracy. It's always a good idea to have someone else also review the form for any potential errors or oversights.

Who needs a self-funded group enrollment form?

1. Employers or organizations offering healthcare benefits: A self-funded group enrollment form is typically required by employers or organizations that provide healthcare benefits to their employees or members.
2. Employees or group members: Individuals who are eligible to enroll in the group health plan offered by their employer or organization will need to fill out the self-funded group enrollment form.

By completing this enrollment form accurately and on time, both employers and employees can ensure that the necessary healthcare coverage is provided to the eligible individuals within the group.

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