STEP 1: APPLICANT’S INFORMATION
Please note: Processing of your application may be delayed if this form is NOT completed in its entirety. PLEASE PRINT CLEARLY.
First Name MI Last Name
Gender
Male
Female
Social Security Number: Date of Birth (Month/Day/Year)
______ /_____ /______
Requested Eective Date
______ /_____ /______
Mailing Address
City State ZIP County State in which you reside
Home Phone Work Phone Mobile Phone
Email Address (If applicable)
Tobacco Use?*
Yes
No
*Question is required and must be completed or your application will be delayed. See back page for further clarification.
STEP 2: CHOOSE YOUR PLAN
Review the product information to learn what each plan covers. The plan and deductible option you choose will apply to everyone
covered by your plan.
Benefit Plans:
BlueDirect Gold 90 (10353824)
BlueDirect Silver 80 3000 (10353825)
BlueDirect Silver 80 2800 (10430436)
BlueDirect Bronze 100 (10353826)
SimplyBlue Bronze 60 (10353827)
BlueCare Gold 70 (10353828)
BlueCare Silver 70 5000 (10353829)
BlueCare Silver 70 4200 (10430437)
BlueEssential (10353830)
Yes No Will any portion of the premium be paid by your employer or your
spouse’s employer, either directly or through wage adjustments or other
means of reimbursement?
Yes No Do you, your employer or any of your Eligible Dependents intend to
treat this health Benefit Plan as part of a plan or program under
Section 162, Section 125 or Section 106 of the U.S. Internal Revenue
Code? (See back page “Coverage Information” for additional explanation.)
Yes
No Is any person applying for this coverage entitled to benefits under
Medicare Part A or enrolled in Medicare Part B?
STEP 3: REASON FOR APPLYING
New coverage (I do not have BCBSND coverage now)
Change in existing BCBSND coverage
Loss of previous health coverage due to:
Legal Separation/Divorce
Death
Termination of Employment/Reduction of Hours
Employer Contribution Terminated
Other __________________________________
Termination letter from previous carrier identifying the reason
for loss of coverage is required.
Life Event: Supporting documentation required:
Annual Enrollment ................................None
Marriage ..................................................... Marriage certificate
Birth ............................................................. Birth certificate
Adoption ....................................................Adoption papers
Legal Guardianship ............................... Legal Guardianship papers
STEP 4: SPOUSE/DEPENDENT(S) TO BE INSURED INFORMATION
(Use extra paper if necessary)
PERSON 2
First Name MI Last Name
Gender
Male
Female
Social Security Number: Date of Birth (Month/Day/Year)
______ /_____ /______
Relationship to You?
Spouse
Child
Stepchild
Grandchild
Adopted
Legal Guardian
Tobacco Use?*
Yes
No
PERSON 3
First Name MI Last Name
Gender
Male
Female
Social Security Number: Date of Birth (Month/Day/Year)
______ /_____ /______
Relationship to You?
Spouse
Child
Stepchild
Grandchild
Adopted
Legal Guardian
Tobacco Use?*
Yes
No
PERSON 4
First Name MI Last Name
Gender
Male
Female
Social Security Number: Date of Birth (Month/Day/Year)
______ /_____ /______
Relationship to You?
Spouse
Child
Stepchild
Grandchild
Adopted
Legal Guardian
Tobacco Use?*
Yes
No
PERSON 5
First Name MI Last Name
Gender
Male
Female
Social Security Number: Date of Birth (Month/Day/Year)
______ /_____ /______
Relationship to You?
Spouse
Child
Stepchild
Grandchild
Adopted
Legal Guardian
Tobacco Use?*
Yes
No
*Question is required and must be completed or your application will be delayed. See back page for further clarification.
STEP 5: SIGN, AUTHORIZE AND DATE APPLICATION
I understand that any company(s) with which I am applying for coverage reserves the right to accept or decline this application in whole or
in part. I further understand that no contractual right is created by this application or advance premium payment and the same shall not be
considered accepted unless or until the Benefit Plan is issued to me. I have read this application in its entirety (including the back page) and
understand and acknowledge that the accuracy and suciency of the information I provide (or fail to provide) in each and every numbered
section of this application serves as the basis in determining my eligibility (and the eligibility of my dependents) for coverage and receiving
a Benefit Plan(s), and by signing this application I certify the information is accurate and complete. I understand and agree that inaccurate,
incomplete or omitted information represented in this application may constitute a fraudulent act or intentional misrepresentation of material
facts voiding or retroactively canceling any Benefit Plan(s) issued, as well as any claims for medical benefits and services paid, based on the
information I submit through this application. I further understand a person who submits an application or files a claim with intent to defraud
or helps commit a fraud against an insurer is guilty of a crime.
X
Applicant’s Signature or Responsible
Adult if Applicant is under age 18
Date Signed
Producer Number Producer Name Producer Signature
WHITE ORIGINAL - BCBSND YELLOW COPY - Producer WHITE COPY - Applicant
29378831 IND FI
29378831 IND FI
