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Commission Acknowledgement Letter
Description:
Required for new large groups and large group renewals.
(ocx
, 34k)
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1/27/2016
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Download
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EFT Form
Description:
For initial payments.
(pdf
, 76k)
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1/27/2016
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Download
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Employer App - all products
Description:
Master app for all lines of coverage
(pdf
, 396k)
Version: 23845P-0813R
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11/6/2014
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Download
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Employer Application - medical only
Description:
Small group Employer Application
(pdf
, 61k)
Version: 20741-0613R SR
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11/6/2014
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Download
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Large Group Underwriting Questionnaire 100+
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1/27/2016
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Download
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Large Group Underwriting Questionnaire 51+
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2/7/2017
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Download
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Employee Application
Description:
Employee enrollment/waiver form for all BCBS coverages
(pdf
, 248k)
Version: 22095 0914R SR
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1/29/2015
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Download
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Employee Application - Spanish
Description:
Spanish version of Employee enrollment for all BCBS medical coverages
(pdf
, 112k)
Version: 22095S - 0210
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6/17/2010
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Download
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Employee Change Form
Description:
Make changes/terminations for all BCBS health products
(pdf
, 227k)
Version: 22411-0813R SR
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1/16/2015
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Download
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Employee Change Form - Spanish
Description:
Make changes/terminations for all BCBS health products
(pdf
, 232k)
Version: 22411S-0813 SR
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11/4/2014
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Download
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Amendment
Description:
Use this form to change group name, plan, waiting period, contribution, etc.
(pdf
, 102k)
Version: 20752-0613
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11/4/2014
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Download
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ATNE
Description:
To Calculate Average Total # of Employees
(pdf
, 104k)
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11/6/2014
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Download
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Common Ownership Form
Description:
For Single Employers
(pdf
, 44k)
Version: 62891-0613 SR
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11/4/2014
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Download
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Enrollment Summary
Description:
This form should be completed for all renewals, As Is or otherwise.
(pdf
, 67k)
Version: 7823 SR 0613
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11/4/2014
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Download
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Grandfathered Plan Certification
Description:
A group health plan that existed on the date of March 23, 2010.
(pdf
, 105k)
Version: 73060-0512
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11/4/2014
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Download
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Appeal Claim form HMO
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11/6/2014
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Download
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Appeal Claim Form Non-HMO
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11/6/2014
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Download
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International Claim Form
Description:
BlueCard Worldwide International Claim Form
(PDF
, 744k)
Version: N13-04-086
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1/27/2010
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Download
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Medical Claim Form
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1/27/2016
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Download
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Prescription Claim Form
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3/4/2016
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Download
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2017 HSA Trifold
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2/7/2017
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Download
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2017 RBG New Census Template
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2/7/2017
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Download
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Small Group Underwriting Guidelines
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4/15/2016
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Download
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Summary of Benefits and Coverage
Description:The purpose of the SBC is to provide employers and employees with standard information, so they can more easily compare plans and make an informed choice about coverage plan options.
(
, 0k)
For more information: Click Here
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10/24/2012
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Website
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