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CLEAR FIELDS Attn: Small Group Enrollment P.O. Box 607 Department A Newark, NJ 07101-0607 Fax (973) 274-2227 www.HorizonBlue.com GROUP ENROLLMENT/CHANGE REQUEST PLEASE USE ALL CAPITAL LETTERS UTILIZING

How to fill out group enrollmentchange request

How to fill out a group enrollment change request:

1. Start by obtaining the group enrollment change form. This form can usually be found on the website or obtained from the human resources department of your organization.
2. Fill in the required information at the top of the form. This typically includes the name of the organization, the group policy number, and the name of the policyholder or group administrator.
3. Provide the effective date of the requested enrollment change. This could be the date when the change should take effect, such as the beginning of the next month or the start of a new policy year.
4. Indicate the type of enrollment change you are requesting. This could be adding or removing members, changing coverage levels, or updating personal information for existing members.
5. List the details of the individuals affected by the enrollment change. Include their full names, dates of birth, and any other relevant information requested on the form. If you are adding new members, provide their contact information and relationship to the policyholder.
6. If applicable, specify the reason for the enrollment change. This could be a life event, such as marriage, divorce, birth/adoption of a child, or loss of other coverage. Make sure to attach any necessary supporting documentation, such as marriage certificates or birth certificates, if required by the insurance provider.
7. Review the form for completeness and accuracy. Ensure that all required fields are filled in and that the information provided is correct. Double-check names, dates, and other crucial details to avoid any processing delays.
8. Sign and date the form. This is typically done by the policyholder or an authorized representative of the group. By signing, you acknowledge that the information provided is accurate, and you authorize the enrollment change.
9. Submit the completed form to the appropriate entity. This could be the HR department of your organization, an insurance broker, or directly to the insurance provider. Follow any specific instructions provided on the form or by your organization to ensure proper submission.

Who needs a group enrollment change request:

1. Employers or group administrators who manage employee benefits and health insurance coverage for their organization.
2. Employees who wish to make changes to their existing group health insurance coverage, such as adding or removing dependents or changing coverage levels.
3. Organizations or groups that provide health insurance coverage to their members, such as associations or unions, may need to submit a group enrollment change request to update coverage details for their members.

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What is group enrollmentchange request?

A group enrollment change request is a form that allows a group to make changes to their enrollment status or coverage.

Who is required to file group enrollmentchange request?

The group administrator or authorized representative is required to file the group enrollment change request.

How to fill out group enrollmentchange request?

The group enrollment change request form must be completed with accurate information regarding the changes being made to the group's enrollment.

What is the purpose of group enrollmentchange request?

The purpose of the group enrollment change request is to ensure that the group's enrollment information is up to date and accurate.

What information must be reported on group enrollmentchange request?

The group enrollment change request must include information such as the group's name, enrollment changes being requested, and effective date of the changes.