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GROUP ENROLLMENT/CHANGE FORM 2014 SUPERIOR COURT OF CALIFORNIA, COUNTY OF KERN New Enrollment Name/Address Change Reinstatement Rehire HEALTH COMP P.O. BOX 45018 FRESNO CA 937185018 (800) 4427247
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How to fill out group re-enrollmentchange form
How to fill out a group re-enrollment/change form:
01
Contact your insurance provider or HR department to obtain the necessary form.
02
Read the instructions carefully before starting to fill out the form.
03
Begin by providing basic information like the group plan number, employer name, and coverage effective date.
04
List all the members who need to be added or removed from the group plan. Include their full names, date of birth, and any other required details.
05
If there are any dependents, provide their relationship to the main policyholder and their relevant information.
06
Indicate the reason for the re-enrollment or change, such as a change in employment status, marriage, birth of a child, or any other qualifying event.
07
If necessary, attach supporting documents such as marriage certificates, birth certificates, or termination letters.
08
Double-check all the information entered before submitting the form to ensure accuracy.
09
Submit the completed form to the appropriate department or address specified by your insurance provider or employer.
Who needs a group re-enrollment/change form:
01
Employers who want to make changes to their group insurance plan, such as adding or removing employees or dependents.
02
Employees who experience qualifying events that require them to update their group coverage, such as marriage, birth, or change in employment status.
03
HR departments or insurance administrators responsible for managing group insurance plans within an organization.
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