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DO NOT USE FOR INTERNAL PURPOSES ONLY HIS ID#___ EC___A nonprofit independent licensee of the Blue Cross Bluesier Association P.O. Box 22999, Rochester, NY 14692Instructions on last page. All Dates

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Employers who are looking to enroll a new group of employees into a company benefit program.

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What is new group enrollment checklisformalthy?

New group enrollment checklist is a form used to enroll new members into a group.

Who is required to file new group enrollment checklisformalthy?

Employers or group administrators are required to file the new group enrollment checklist.

How to fill out new group enrollment checklisformalthy?

To fill out the new group enrollment checklist, provide the required information for each new member being enrolled.

What is the purpose of new group enrollment checklisformalthy?

The purpose of the new group enrollment checklist is to accurately enroll new members into a group health plan.

What information must be reported on new group enrollment checklisformalthy?

Information such as member name, date of birth, gender, contact information, and dependent information must be reported on the new group enrollment checklist.

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