Individual and Family Change Request Form

Use this form if you have an Individual and Family policy and experience certain life changes outside the annual Open Enrollment Period. These life changes can affect coverage, and therefore require you to submit a Change Request form:

• Adding a dependent or spouse*

• Moving to or within South Carolina*

• Voluntarily dropping a dependent or spouse from your policy


Download the 2022 Change Request Form.


*These changes also require documentation to show that you’re eligible for a Special Enrollment Period.

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