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CLEAR FIELDS Attn: Small Group Enrollment P.O. Box 607 Department A Newark, NJ 071010607 Fax (973× 2742227 www.HorizonBlue.com GROUP ENROLLMENT×CHANGE REQUEST PLEASE USE ALL CAPITAL LETTERS UTILIZING
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How to fill out group enrollmentchange request
How to fill out a group enrollment change request:
01
Start by obtaining the group enrollment change request form. This form is usually provided by the insurance company or the employer's human resources department.
02
Begin by filling out the basic information section of the form. This typically includes the name of the company or organization, the group insurance policy number, the effective date of the change, and the contact information of the person submitting the request.
03
In the next section, provide the details of the requested change. This may include adding or removing members from the group coverage, changing the coverage type (e.g., adding dental or vision), or updating personal information for existing members.
04
Make sure to accurately fill out all the required fields on the form. These may include the names of the individuals being added or removed, their Social Security numbers or employee identification numbers, and any other relevant information.
05
If the requested change is due to a qualifying event, such as marriage, birth, adoption, or loss of other coverage, include the necessary documentation to support the change. This can include marriage certificates, birth certificates, or termination letters from previous insurers.
06
Review the completed form thoroughly to ensure all information is accurate and legible. Double-check spellings, addresses, and other details to avoid any processing delays or errors.
07
Once the form is complete, sign and date it as the authorized representative submitting the request. If you are submitting the form electronically, follow the instructions provided by the insurance company or employer.
Who needs a group enrollment change request?
01
Employers or their designated representatives often need a group enrollment change request form to process changes to their employees' health insurance coverage.
02
Employees may need a group enrollment change request form if they experience a qualifying event that allows them to make changes to their existing coverage, such as adding a new dependent or switching to a different plan.
03
Insurance companies require a group enrollment change request form to properly update and maintain accurate records of policyholders and ensure the appropriate coverage is provided to members of the group.
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What is group enrollmentchange request?
Group enrollment change request is a form submitted to make changes to a group enrollment, such as adding or removing members.
Who is required to file group enrollmentchange request?
Employers or group administrators are required to file group enrollment change request.
How to fill out group enrollmentchange request?
Group enrollment change request should be filled out with information about the changes being made, such as adding or removing members.
What is the purpose of group enrollmentchange request?
The purpose of group enrollment change request is to update the group enrollment with any changes that have occurred.
What information must be reported on group enrollmentchange request?
Group enrollment change request must include details of the changes being made, such as names of members being added or removed.
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