1. Please indicate reason for Application:
M
M
New Subscriber(s)
MM
Coverage Change
MM
Cancel
MM
Miscellaneous
2. EFFECTIVE DATE OF ACTION REQUESTED: DATE OF HIRE: ELIGIBILITY DATE:
MONTH DAY YEAR MONTH DAY YEAR MONTH DAY YEAR
3. Type Contract: M Preferred Blue
MEMBERSHIP APPLICATION
BLUE CROSS
®
AND BLUE SHIELD
®
OF SOUTH CAROLINA, An independent licensee of the Blue Cross and Blue Shield Association
COMPANION HEALTHCARE, A wholly-owned subsidiary of Blue Cross and Blue Shield of South Carolina, An independent licensee of the Blue Cross and Blue Shield Association
COMPANION LIFE INSURANCE COMPANY, A wholly-owned subsidiary of Blue Cross and Blue Shield of South Carolina.
14.
Check type membership for each coverage desired.
.
S – Single
F – Family
F – Employee/Children
8 – Employee/Spouse
4. Employee — Last Name First Initial Home Telephone No.
6. Mailing Address (Street or P.O. Box) (City) (State) (Zip Code) (County Code - see back)
7.
Name of Employer
Presbyterian College
8. Blue Cross Group Number
TYPE MEMBERSHIP AND COVERAGE INFORMATION
OTHER INSURANCE INFORMATION
EMPLOYEE CERTIFICATION
IDENTIFICATION
REASON FOR COVERAGE CHANGE
9. Dept. No. 10. Payroll No.
12. Name of spouse to be
excluded from coverage if
applicable
13. Occurrence Date or
Left Employment Date
Mo. Day Yr.
––
11. Check appropriate reason; give occurrence date in Block 13:
A M Birth or Adoption C M Divorce F M Attained Reduction Age
B M Death (Name: ) D M Marriage
E M Other – Explain:
16.
Do you or does any member of your family have other health, dental or drug coverage, Federal Employees’ Program (FEP) or Medicare? M YES M NO
If Yes: MEDICARE A M Effective Date MEDICARE B M Effective Date
A. Family Member’s Name and Social Security No.
B. Name of Insurance Co. Policy No. Effective Date
C. Family Member’s Employer
D. List Names of Covered Persons 1 2 3 4
E. Please circle each type of service covered by this policy: Hospital, Physician/Medical, Prescription Drugs, Dental, Vision
17. Employee Certification –
I HAVE READ AND UNDERSTAND EACH AND EVERY PART OF THIS ENROLLMENT APPLICATION.
Date: Signature:
15.
List All Family Members Covered or Affected By a Change
YOURSELF:
Spouse
Social Security No.
Child
Social Security No.
Child
Social Security No.
Child
Social Security No.
Sex
Last Name First
Initial
Birthdate
Mo. Day Yr.
5. Social Security No.
x
click to sign
signature
click to edit
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