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STATE OF LOUISIANA OFFICE OF GROUP BENEFITS ENROLLMENT CHANGE FORM AGENCY NUMBER AGENCY NAME PRIMARY PLAN PARTICIPANT / EMPLOYEE NAME (PAGE 1 of 2) DATE OF HIRE Section 1 Primary Plan Participant
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gb-01 enrollmentchange bformb is a form used to make changes to enrollment information.
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Fill out the form with accurate enrollment information and submit it according to the instructions provided.
The purpose of gb-01 enrollmentchange bformb is to update enrollment information accurately and timely.
Information such as changes in enrollment status, personal details, and any other relevant information must be reported on gb-01 enrollmentchange bformb.
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