Fillable Application / Change Form (Town of Rowe)

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Application / Change Form (Town of Rowe)

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The Application / Change Form (Town of Rowe) form is 2 pages long and contains:

  • 1 signature
  • 53 check-boxes
  • 60 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Town of Rowe

BROWSE TOWN OF ROWE (MA) FORMS

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New Enrollee
(Please complete Sections A, C, D, and E.)
Change Request
(For changes, complete Sections A, B, and all other applicable
sections. Plan changes can only be made at Open Enrollment or due
to a qualifying event.)
Termination Date:
Blue 20/20 Group No.
Application / Change Form
A. Employee Information
Name of Employer: Effective Date: Dept./Division:
Social Security Number: Date of Birth: Sex:
Male Female
Last Name: First Name: MI: Marital
Status: Single Married
Mailing Address: City: State: ZIP Code:
Date of Hire: Home Phone Number: Work Phone Number: Email Address:
B. If Making a Change from Previous Enrollment
Check All That Apply:
Name Change
Employee SSN Correction
Add/Remove Dependent
Address/Telephone Number Change
Date of Birth Correction
Late Enrollee
Other:
Add Dependent(s):
Date of Occurrence
Marriage
Newborn (up to age 1)
Adoption
Court Order
Loss of Coverage
Other
Remove Dependent(s)
Date:
Reason:
Reinstate Coverage:
Date:
Reason:
Terminate Coverage:
Date:
Reason:
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.
Please print clearly.
Please use a black or blue pen.
20246
Town of Rowe
C. Coverage Selection
Options Selected: Employee
Employee plus Spouse
Employee plus One or More Children Family
D. Family Information—Complete for anyone taking or dropping Blue 20/20 Coverage*
Name
(First, MI, Last Name)
Social Security
Number
Date of Birth
mm/dd/yyyy
Relationship Sex
Add
Delete
M
F
Add
Delete
M
F
Add
Delete
M
F
Add
Delete
M
F
Add
Delete
M
F
Add
Delete
M
F
Add
Delete
M
F
*Application does not guarantee enrollment.
Eligibility Notes:
1. Employees are eligible for coverage if they meet the definition of an eligible employee as defined by their employer and
Blue Cross Blue Shield of Massachusetts.
2. Dependent Children are eligible for coverage up to age 26.
E. Statement of Understanding
The information here is complete and true. I understand that Blue Cross and Blue Shield will rely on this information to enroll
me and my dependents or to make changes to my membership. I understand that I should read the subscriber certificate or
benefit booklet provided by my employer to understand my benefits and any restrictions that apply to my vision plan.
Signature of Employee Date
Visit us at blue2020ma.com
® Registered Marks of the Blue Cross and Blue Shield Association. © 2019 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
194827M 55-0554 (02/19) 2.5C
Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the
basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity.
ATTENTION: If you don’t speak English, language assistance services, free of charge, are available to you. Call Member Service
at the number on your ID Card (TTY: 711).
ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio
al Cliente que gura en su tarjeta de identicación (TTY: 711).
ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços
aos Membros, através do número no seu cartão ID (TTY: 711).
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Application Change Form (Town of Rowe)

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Completed 16 July 2020

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