POD 29316782 • 2-19
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Employee Change Form
Return completed forms by:
Attn: Enrollment Department
4510 13th Ave. S.
Fargo, ND 58121
Group Information
Group Name (please print)
Employee Information
Employee Name (please print)
Unique Member Identifier
Request for Updating Employee Information
Updating Employee Information
Name Change
Eective Date (MM/DD/YYYY)
Address Change
Eective Date (MM/DD/YYYY)
Name Change
First Name Middle Name Last Name
Address Change
Address Line 1
Address Line 2
City State Zip
Request for Cancellation (Reason field is required. Cancellation may be delayed without completing reason.)
Employment Terminated
No Reason_____________________________________
BCBSND health Group Number:_________________
Eective Date (MM/DD/YYYY)
Dental coverage Group Number:_________________
Eective Date (MM/DD/YYYY)
Vision coverage Group Number:_________________
Eective Date (MM/DD/YYYY)
Group Contact
Group Contact Information
Name (please print) Phone Number
Authorized Signature Date