Fillable Bcbsenrollment (Arkansas Tech University)

Fill Online, Printable, Fillable, Blank Bcbsenrollment (Arkansas Tech University) Form

Use Fill to complete blank online ARKANSAS TECH UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Bcbsenrollment (Arkansas Tech University)

On average this form takes 30 minutes to complete

The Bcbsenrollment (Arkansas Tech University) form is 2 pages long and contains:

  • 0 signatures
  • 54 check-boxes
  • 95 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Arkansas Tech University

BROWSE ARKANSAS TECH UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
  SECTION 1. POLICY ELIGIBILITY
SECTION 3. MARITAL STATUS
Please check the appropriate box and ll in blanks below in ink.
COBRA Effective Date
  Mo Day Year
Date of Full-Time Employment
  Mo Day Year
Reason for COBRA:
____________________
     Yes     No If No, retirement date: _____________________
 
Are you a current, active employee?
Group No.: Employer: I.D. No.:
FOR OFFICE USE ONLY
COBRA Termination Date
  Mo Day Year
GROUP EMPLOYEE APPLICATION
Is the Employee waiving coverage in the plan? l Yes l No If yes, complete Sections 2, 6 & 9 only.
Group AdministrAtor use only
Multi-option: which ___________
Relationship
M.I.
Social Security No.
First Name
Sex
Last Name
Date
of Birth
Self
l Arkansas Blue Cross and Blue Shield l Health Advantage
NOTE: Areas in Green apply to Health Advantage only.
Check all applicable boxes below that support your eligibility and provide date of qualifying life event.
o 1-Annual Open Enrollment Period
o 2-New Enrollee
o 3-New Enrollee-Life Only
(Omit Section 7)
o 4-Loss of Minimum Essential Coverage
o 5-Newborn
o 6-Marriage
o 7-New Adoption
o 8-New Guardianship/Legal custody/Court order to add child
o 9-Other: Reason _________________________________
_____________________________________________
Date
_________
_________
_________
_________
Date
_________
_________
_________
_________
Coverage Desired: l Employee Only l Employee & Spouse l Employee & Child(ren) l Employee, Spouse & Child(ren)
$ Amt
Deductible
Credit
Submitted*
Was This
Your
Regular
Physician?
PCP
Number
(NPI#)
Primary
Care
Physician
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
*Deductible Credit is available for new group enrollments with Arkansas Blue Cross (Not Health Advantage) but only if the individual requests it on this initial application.
o Single (including widowed or divorced)
o Married (including separated)
SECTION 4. CONTACT INFORMATION
Street or P.O. Box _______________________________ City ____________________________ State _____ Zip _________
Primary Phone Number
( )___________
Work Phone Number
( )___________
E-mail Address ______________________
SECTION 5. EMPLOYMENT STATUS
Job Title __________________________________
l
Hourly Hours Worked Weekly __________
l
Salaried
l
Other
10-04APP 1/14
FOR OFFICE USE ONLY
EFF DATE
DATE
OTH
C/T PKG LIFE
UND
NOTE: If Application is not received during Open Enrollment Period, we must receive appropriate documentation with this Application to
conrm qualifying life event/ special election period (i.e. copy of birth certicate, copy of marriage license, Certicate of Creditable Coverage
from previous insurance company, legal guardianship/custody documentation etc.).
SECTION 2. WHO IS APPLYING (Complete this section on all members to be covered or waived)
Waiving (
✓
)
✔
✔
10-04APP 1/14
To be completed if coverage is declined or refused by an eligible employee and/or their eligible family members.
l Covered by spouse’s group coverage – Carrier Name and ID:
l Enrolled in other Insurance Carrier Plans – Carrier Name and ID:
l Medicare l Medicaid l Covered by TRICARE or CHAMPVA
l Other (Explain):
1. Medical Coverage Declined For:
l Myself
l Spouse
l Dependents
I hereby certify that: (1) I have been given the opportunity to apply for the coverage made available through my employer
under the applicable policy. The coverages and the policy have been thoroughly explained to me, and I decline to apply for
coverage for myself and/or my dependent(s) as listed above; and (2) I understand that if I refuse to apply now and I apply for
coverage at a later date, I will be deferred until open enrollment.
SECTION 6. WAIVER OF ENROLLMENT
SECTION 7. CURRENT/PREVIOUS INSURANCE INFORMATION
Print Name of Applicant (Employee)
Date
Date
Print Employer/Group Representative*
Signature of Applicant (Employee)
Signature Employer/Group Representative*
*Required for new hires and additions only.
First Name M.I. Last Name Date of Birth Relationship
SECTION 9. SIGNATURES (PLEASE READ BEFORE SIGNING IN INK.)
I understand that the benets for which I (we) will be eligible are those described in the Arkansas Blue Cross and Blue Shield, Health Advantage
and USAble Life group policies with my employer as may from time to time be amended. I understand that coverage will not become effective
before the approved effective date.
In signing this application, I represent that the statements and answers given in this application are true, complete and correctly recorded.
I understand that Arkansas Blue Cross and Blue Shield, Health Advantage or USAble Life may, within three years of the date of this
application, void or terminate this coverage or deny claims for coverage if incorrect information has been given on this application. If fraudulent
misstatements were made, Arkansas Blue Cross and Blue Shield, Health Advantage or USAble Life may take legal action at any time.
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benet or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to nes and connement in prison.
(This section must be completed to process your enrollment application.)
l
Yes
l
No On the day coverage begins will any family members be covered by other health or dental insurance or Medicare,
including continuation of coverage? If yes, answer all questions below. (Use additional paper if necessary)
l
Yes
l
No Is the continuing coverage Medicare? If so, complete the following:
Reason for Medicare coverage:
l
Over 65
l
Disabled
l
Kidney Disease
Medicare Beneciary Name: Relationship of Beneciary to Policyholder:
Medicare Health Identication Contract (HIC) Number:
Type of Medicare Coverage (check all that apply)
l
Medicare Part A – Effective Date:
l
Medicare Part B – Effective Date:
l
Yes
l
No Is the continuing coverage other than Medicare? If so, complete the following: (if covered by more than one insurance plan, use additional paper)
Name of Insurer
Policyholder Name
Address
Date of Birth
  Phone
Member ID #
USAble Life is an independent company and operates separately from Arkansas Blue Cross and Blue Shield and Health
Advantage. USAble Life does not sell or service Arkansas Blue Cross and Blue Shield or Health Advantage products.
USAble Life is solely responsible for life insurance.
I hereby designate the beneciary or beneciaries listed below under this certicate and revoke the appointment of any existing beneciary
.
SECTION 8. LIFE INSURANCE (Issued by USAble Life if purchased by your employer)
First Name
For members listed above, are you responsible for providing primary health insurance coverage? l Yes l No 
If No, please name responsible party: _____________________________________
Last Name Relationship Effective Date of Coverage
✓
List the following information for all family members covered by this policy (indicate those not residing in your household with a check ✓ mark)
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Bcbsenrollment (Arkansas Tech University)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 21 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document