Enrollment Questionnaire

Please complete and submit this Enrollment Questionnaire to help speed up access to your benefits.

This checklist will help you be prepared to answer all of the questions on the form.

If you need assistance, please contact us

This information is being submitted via a secured connection. Please see our privacy policy for more information.

Self Plus One Enrollment Information - Spouse and Dependent Information

First Name

Middle Initial (Optional)

Last Name

Preferred Name (Optional)

If you commonly use a name other than your first name, please enter that here.

Date of Birth

Relationship to Member

Gender

Disabled Yes
No

We ask the disabled status of your dependents over the age of 26 in order to comply with the Office of Personnel Management (OPM). We do not need the disabled status for your spouse.

Social Security Number

The Affordable Care Act requires health insurers to collect Social Security Numbers to report coverage to the Internal Revenue Service.

Family Enrollment - Spouse and Dependent Information

First Name

Middle Initial (Optional)

Last Name

Preferred Name (Optional)

If you commonly use a name other than your first name, please enter that here.

Date of Birth

Relationship to Member

Gender

Disabled Yes
No

We ask the disabled status of your dependents over the age of 26 in order to comply with the Office of Personnel Management (OPM). We do not need the disabled status for your spouse.

Social Security Number

The Affordable Care Act requires health insurers to collect Social Security Numbers to report coverage to the Internal Revenue Service.

Member Signature

Today's Date

Enrollment Questionnaire

Member Information

Primary Contact Information

Alternate Contact Information

Plan Information

Self Plus One Enrollment Information - Spouse and Dependent Information

Family Enrollment - Spouse and Dependent Information

Other FEHB Coverage Information

Other Non-Federal Coverage Information

Workers Compensation Information

Medicare Information

HDHP Plan Information