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Retail to:UNGROUP ENROLLMENT×CHANGE REQUEST. Type of Activity to be completed by Applicant 1. ADD Enrollment of a new Subscriber Add Spouse Add Civil Union Partner 2. REMOVE Spouse Remove Civil Union
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01
Open the PDF non-group enrollment change request form.
02
Read the instructions carefully.
03
Fill in your personal details, including your name, address, and contact information.
04
Provide your current health insurance plan details, such as the plan name and policy number.
05
Indicate the type of enrollment change you want to make, whether it's adding a dependent, removing a dependent, or changing your coverage level.
06
Fill out the necessary information for the enrollment change, such as the name and relationship of the dependent to be added or removed.
07
Review the completed form to ensure all information is accurate and complete.
08
Sign and date the form.
09
Submit the form as per the instructions provided.

Who needs pdf non-group enrollmentchange request?

01
Anyone who is enrolled in a non-group health insurance plan and wishes to make changes to their enrollment needs the PDF non-group enrollment change request.
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PDF non-group enrollment change request is a form used to request changes in enrollment for individuals outside of a group plan.
Individuals who are enrolled in a non-group health insurance plan are required to file the PDF non-group enrollment change request.
To fill out the PDF non-group enrollment change request, you need to provide your personal information, current enrollment details, requested changes, and any supporting documentation.
The purpose of the PDF non-group enrollment change request is to allow individuals to make changes to their health insurance enrollment outside of the open enrollment period.
The PDF non-group enrollment change request must include personal information, current plan details, requested changes, and any supporting documentation.
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