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651 Perimeter Drive, Suite 300, Lexington, KY 40517 Phone: 800-787-2680 Fax: 859-335-3750 EMPLOYER Complete this Section 1 Small Group Enrollment Form Applicants should use this form to apply for

How to fill out small group enrollment form

How to fill out a small group enrollment form:

1. Begin by reviewing all the instructions provided with the form. Make sure you understand each section and what information is required.
2. Start by filling out the basic information section, including your name, address, phone number, and email address. Provide accurate and up-to-date information.
3. If applicable, indicate your relationship to the primary member or policyholder. This could be a spouse, child, or dependent.
4. Move on to the section where you need to provide information about your current healthcare coverage. Include details such as the name of the insurance company, policy number, and the coverage start and end dates.
5. Next, provide information about any dependents you want to enroll in the small group plan. Include their names, dates of birth, social security numbers (if required), and relationship to you.
6. Evaluate any additional coverage options that may be available, such as dental or vision insurance. If you want to enroll in these additional plans, be sure to select the appropriate box or provide the required information.
7. Review all the information you have entered for accuracy and completeness before submitting the form. Double-check spellings, dates, and other details.
8. Sign and date the form. If required, have any necessary witnesses or authorized individuals sign as well.
9. Finally, submit the completed form to the designated recipient or as instructed in the provided guidelines.

Who needs a small group enrollment form?

1. Employers who want to offer health insurance coverage to their employees through a small group plan.
2. Employees who want to enroll in a health insurance plan provided by their employer.
3. Dependents of employees who are eligible for coverage under the small group plan. This may include spouses, children, or other qualifying family members.

Please note that the specific requirements and procedures for filling out a small group enrollment form may vary depending on the insurance provider and the regulations of your country or state. It is always best to consult the provided instructions or seek assistance from the employer's human resources department or insurance representative if you have any questions or concerns.

For pdfFiller’s FAQs

What is small group enrollment form?

Small group enrollment form is a document used to enroll a small group of individuals in a health insurance plan.

Who is required to file small group enrollment form?

Employers with a small group of employees who are eligible for health insurance coverage are required to file the small group enrollment form.

How to fill out small group enrollment form?

To fill out the small group enrollment form, the employer must provide information about the eligible employees, including their names, dates of birth, and coverage options.

What is the purpose of small group enrollment form?

The purpose of the small group enrollment form is to enroll eligible employees in a health insurance plan offered by the employer.

What information must be reported on small group enrollment form?

The small group enrollment form must include information about the eligible employees, such as their names, dates of birth, and coverage options.

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