Fillable Group Enrollment Application/ Change Form (Blue Cross and Blue Shield of Illinois)

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Group Enrollment Application/ Change Form (Blue Cross and Blue Shield of Illinois)

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The Group Enrollment Application/ Change Form (Blue Cross and Blue Shield of Illinois) form is 5 pages long and contains:

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  • 162 check-boxes
  • 188 other fields

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Please read the instructions on the inside thoroughly before completing this
enrollment application/change form.
Group Enrollment
Application/Change Form
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Life and Disability insurance is underwritten by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Dearborn Life Insurance Company is an independent Blue Cross and Blue Shield licensee.
BLUE CROSS,
®
BLUE SHIELD
®
and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. 232320.0919
ENROLLMENT APPLICATION/CHANGE FORM INSTRUCTIONS
PLEASE READ THOROUGHLY BEFORE COMPLETING ENROLLMENT APPLICATION/CHANGE FORM. USE A BLACK OR BLUE BALLPOINT PEN ONLY. PRINT NEATLY. DO NOT ABBREVIATE.
SECTION 1
ENROLLMENT EVENTS
Check all the boxes that apply to indicate if you are a new enrollee or if you are requesting a change to your coverage. Indicate the event and date, if applicable. Complete the
additional sections that correspond to your selection.
New Enrollee: Complete all sections where applicable.
Add Dependent: Complete all sections where applicable.
• If you are applying for coverage for a disabled dependent over the age limit of your employer’s plan, please provide the additional information requested in Section 5.
Additional documentation may be required as addressed in that section.
• If your employer oers coverage for children and your children are eligible, your children are eligible for health and/or dental coverage up to the dependent limiting age
and may not be denied coverage due to marital, student or employment status before age 26 (check with your employer for additional details regarding eligibility
requirements). In addition, eligible military personnel may not be denied coverage before age 30 under Illinois law. If you are adding an eligible military personnel
dependent who is over the age limit of the employer’s plan, completion of a Defense Department Form (DD 214) is required in addition to this application.
Open Enrollment: The period of time oered on a regular basis during which you can elect to enroll in a specic group health insurance plan or make changes to your
current membership.
Special Enrollment Event: If you qualify, special enrollment is any change to your current membership such as marriage*, divorce**, adoption, suit for adoption or
placement for adoption, leave/layo, moving out of the service area, etc. This change may occur outside of open enrollment.
Eective Date of Benets: Field is mandatory and should reect your requested date.
Completion of Other Eligibility Requirements: Check this box only if your employer has eligibility requirements that you have met/completed prior to enrollment,
such as measurement period or orientation period.
Cancel Enrollee/Cancel Dependent/Cancel Coverage: Complete Sections 1, 2, 4 (skip Section 4 if declining coverage), 8 and 9. In Section 4 include name, social
security number and date of birth of individual(s) canceling.
SECTION 2
YOUR INFORMATION
Complete this section with details about yourself even if you are declining coverage.
SECTION 3
YOUR COVERAGE
Complete all portions related to the coverages for which you are applying. Please list the seven character plan ID for your selected benet design (example: S533PPO) in the
plan # eld. If you are unsure of your group size or do not know your plan ID, please ask for guidance from your employer.
If you are enrolling for life or disability insurance enter the information requested. When listing the beneciary, provide both the rst and last name and the relationship to
you. List all beneciaries that apply.
SECTION 4
COVERAGE OPTIONS
Complete all areas that apply to you and each dependent.
For HMO Plans Only:
•  Those applying for HMO coverage are required to select a primary care physician/practitioner (PCP) for each covered individual. List the name of the physician/
practitioner and the provider number from the provider directory or Provider Finder
®
at bcbsil.com. Be sure to check the appropriate box for a new patient.
•  If you selected HMO coverage, you must select a medical group/individual practice associations (IPAs) and a primary care physician (PCP) for each person to be
covered.
You must also select a PCP within the selected medical group/IPA for each person to be covered. You may choose a dierent medical group/IPA for each person. Care
received from a woman’s principal health care provider (WPHCP) may be eligible for coverage without referrals from your PCP. However, your PCP and your WPHCP
must be aliated with or employed by your medical group/IPA in order for each person to be eligible for coverage. Until we receive your selected medical group/IPA,
you may not be eligible and your claims may be denied. Be sure to enter the medical group/IPA number, name, PCP number and name.
•  If you are adding an eligible military personnel dependent who is over the age limit of your employer’s plan, completion of a Defense Department Form 214 (DD 214) is
required in addition to this application.
Change Primary Care Physician/Practitioner: Complete Section 1 and check the “Other Change(s)” box; then, complete Sections 2, 3, 4 and 9. In Section 4, please include
enrollee’s or dependent’s name, social security number, date of birth, name and number of the new PCP and the name and number of the new IPA.
Change Address/Name: Complete Section 1 and check the “Other Change(s)” box; then, complete Sections 2 and 9.
SECTION 5
DISABLED DEPENDENT
A disabled dependent must be medically certied as disabled and dependent upon you or your spouse***/domestic partner in order to be considered for coverage if
dependent coverage is part of your employer’s plan. The disabled dependent is required to be covered prior to age 26 to be eligible for coverage over the dependent child
age limit of your employer’s plan. A Disabled Dependent Authorization and Disabled Dependent Physician Certication document must be completed and submitted with this
enrollment application, if applicable.
SECTION 6
OTHER COVERAGE
Complete this section if you or any dependent have other group or individual health and/or dental coverage (if applicable) that will not be canceled when the coverage under
this application becomes eective.
SECTION 7
MEDICARE COVERAGE
Complete this section if you or any of your dependents are covered by Medicare. Enter the start and end dates for the coverage that applies. Your Medicare HIC number must
be listed (it can be found on your Medicare ID card). Check the reason for your Medicare coverage.
SECTION 8
DECLINATION OF
COVERAGE
Complete this section if you are declining health coverage for yourself and your dependents. Anyone declining coverage for any reason should complete Section 8, not just
those declining because of other coverage.
IMPORTANT NOTICE: If you are declining enrollment for yourself or your dependents (including your spouse) because of other health care coverage, you may, in the
future, be able to enroll yourself or your dependents in the plan if you request enrollment within 31 days after your other coverage ends. In addition, if you have a new
dependent as a result of a marriage, party to a civil union, birth, adoption, becoming a party in a suit for adoption, or placement of a foster child in your home, you may be
able to enroll yourself and your dependents if you request enrollment within 31 days after the marriage, birth, adoption, suit for adoption or placement for adoption, or
placement of an eligible foster child in your home.
SECTION 9
COVERAGE CONDITIONS
SIGN YOUR NAME AND DATE THE ENROLLMENT APPLICATION IF YOU AGREE TO THE CONDITIONS SET FORTH IN THIS SECTION. YOUR ENROLLMENT APPLICATION SHOULD BE
SUBMITTED TO YOUR EMPLOYER’S
ENROLLMENT DEPARTMENT, WHICH WILL THEN SUBMIT YOUR FORM TO BCBSIL.
AS USED ON THE APPLICATION (UNLESS INDICATED OTHERWISE): THESE TERMS MAY BE USED IN A DIFFERENT WAY IN OTHER DOCUMENTS.
* THE TERM “MARRIAGE” INCLUDES LEGAL MARRIAGE AND THE ESTABLISHMENT OF A CIVIL UNION OR DOMESTIC PARTNERSHIP (COVERAGE SUBJECT TO YOUR EMPLOYER’S PLAN).
** THE TERM “DIVORCE” INCLUDES LEGAL DIVORCE AND THE COMPARABLE TERMINATION OF A CIVIL UNION OR DOMESTIC PARTNERSHIP (COVERAGE SUBJECT TO YOUR EMPLOYER’S PLAN).
*** THE TERM “SPOUSE” INCLUDES A LEGAL SPOUSE AND A PARTY TO A CIVIL UNION OR DOMESTIC PARTNERSHIP (COVERAGE SUBJECT TO YOUR EMPLOYER’S PLAN).
CHANGES IN STATE OR FEDERAL LAW OR REGULATIONS, OR INTERPRETATIONS THEREOF, MAY CHANGE THE TERMS AND CONDITIONS OF COVERAGE.
IF YOU ARE A CURRENT MEMBER AND HAVE QUESTIONS, YOU MAY CALL THE CUSTOMER SERVICE NUMBER ON THE BACK OF YOUR MEMBER ID CARD.
232320.0919 bcbsil.com 2
SECTION 1 — ENROLLMENT EVENTS PLEASE CHECK ALL THAT APPLY – IF YOU ARE DECLINING COVERAGE, COMPLETE SECTIONS 2, 8 AND 9 ONLY
□
NEW ENROLLEE
□
ADD DEPENDENT
□
OPEN ENROLLMENT
□
OTHER CHANGES
ARE YOU APPLYING AS A RESULT OF A SPECIAL ENROLLMENT EVENT?
□
NO
□
YES, EVENT DATE:
EVENT:
□
NEW HIRE
□
MARRIAGE*
□
BIRTH
□
ADOPTION, PLACEMENT FOR ADOPTION OR SUIT FOR ADOPTION (PROVIDE LEGAL DOCUMENTS)
□
COURT ORDER (PROVIDE COURT ORDER OR DECREE)
□
LOSS OF OTHER COVERAGE
□
OTHER (EXPLAIN):
EFFECTIVE DATE OF BENEFITS:
□
COMPLETION OF OTHER ELIGIBILITY REQUIREMENTS
□
CANCEL ENROLLEE
□
CANCEL DEPENDENT
CANCEL COVERAGE:
□
HEALTH
□
DENTAL
□
TERM LIFE
□
DEPENDENT LIFE
□
SHORT-TERM DISABILITY
□
LONG-TERM DISABILITY
LIST NAMES OF THOSE CANCELING IN SECTION 4 BELOW
EVENT:
□
DIVORCE**
□
DEATH
□
TERMINATED EMPLOYMENT
□
OTHER
INDICATE EVENT DATE:
SECTION 2 — PLEASE TELL US ABOUT YOURSELF COMPLETE EVEN IF DECLINING COVERAGE
LAST NAME FIRST NAME MI (OPT) SUFFIX BIRTH DATE (MM/DD/YYYY) SOCIAL SECURITY #
MAILING ADDRESS - STREET - APT # CITY STATE ZIP CODE
EMAIL ADDRESS
□
MALE
□
FEMALE
HOME/CELL PHONE #
NAME OF EMPLOYER JOB TITLE BUSINESS PHONE # EMPLOYMENT DATE (MM/DD/YYYY)
ON AVERAGE, HOW
MANY HOURS A
WEEK DO YOU WORK?
(REQUIRED)
ELIGIBILITY STATUS: 
□
ACTIVE EMPLOYEE  
□
RETIRED EMPLOYEE - DATE OF RETIREMENT:
□
COBRA COVERAGE START DATE PROJECTED END DATE
□
ILLINOIS CONTINUATION (INSURED PLANS ONLY) START DATE   PROJECTED END DATE
SECTION 3 — SELECT YOUR COVERAGE PLEASE CHECK ALL THAT APPLY
SMALL GROUP PLANS (1-50 EMPLOYEES)
AFFORDABLE CARE ACT PLANS
□
PPO
□
OTHER
□
BLUE CHOICE PREFERRED PPO
SM
□
BLUE OPTIONS
SM
□
BLUE PRECISION HMO
SM
□
BLUECARE DIRECT
SM
PLAN # (REQUIRED)
GRANDFATHERED AND GRANDMOTHERED/TRANSITIONAL PLANS
□
BLUE ADVANTAGE ENTREPRENEUR PPO
SM
□
BLUE ADVANTAGE HMO
SM
□
BLUE CHOICE SELECT PPO
SM
□
BLUE ADVANTAGE HMO VALUE CHOICE
SM
□
BLUE EDGE SELECT HSA
SM
□
COMMUNITY PARTICIPATION ORGANIZATION (CPO)
□
BLUE EDGE HSA
SM
□
CPO VALUE CHOICE
□
BLUE EDGE HCA DIRECT
SM
□
OTHER
□
PPO VALUE CHOICE PLAN # (REQUIRED)
MID-MARKET AND LARGE GROUP STANDARD PLANS (51+ EMPLOYEES) PREVIOUS BCBSIL OR HMO MEMBERSHIP
MID-MARKET & LARGE GROUP STANDARD PLANS 51+
□
PPO
□
BLUE CHOICE OPTIONS
SM
□
BLUE EDGE SELECT HSA
SM
□
BLUE ADVANTAGE HMO
SM
□
BLUE CHOICE SELECT PPO
SM
□
PLAN # (REQUIRED)
□
BLUE ADVANTAGE HMO VALUE CHOICE
SM
□
BLUE EDGE HSA
SM
□
OTHER
GROUP #:
SECTION #:
IDENTIFICATION #:
LARGE GROUP CUSTOM PLANS (151+ EMPLOYEES)
□
TRADITIONAL
□
PPO
□
CPO
□
CPO VALUE CHOICE
□
HMO ILLINOIS
®
□
HMO ILLINOIS
®
W/HCA
□
BLUE ADVANTAGE HMO
SM
□
BLUE ADVANTAGE HMO
SM
W/HCA
□
BLUE CHOICE OPTIONS
SM
□
BLUE CHOICE SELECT PPO
SM
□
BLUE EDGE HCA
SM
□
BLUE EDGE HSA
SM
□
BLUE EDGE HCA DIRECT
SM
□
BLUE EDGE SELECT HCA
SM
□
BLUE EDGE SELECT HSA
SM
□
BLUE EDGE SELECT HCA DIRECT
SM
□
VISION
□
HEARING
□
MEDICARE SUPPLEMENT
□
OTHER
DENTAL
□
BLUECARE DENTAL PPO
SM
□
BLUECARE DENTAL HMO
SM
□
DENTAL GROUP #
(IF DIFFERENT THAN MEDICAL GROUP POLICY #)
□
EMPLOYEE AND PARTY TO A CIVIL
UNION OR DOMESTIC PARTNER
□
MALE
□
FEMALE
□
INDIVIDUAL/EMPLOYEE
□
EMPLOYEE/CHILDREN
□
EMPLOYEE/SPOUSE
□
FAMILY
PRIMARY LANGUAGE
GROUP TERM LIFE, ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) AND DISABILITY INSURANCE
□
I AM NOT APPLYING FOR GROUP TERM LIFE, AD&D OR DISABILITY INSURANCE COVERAGE
EMPLOYEE OCCUPATION/JOB TITLE: WAGE RATE $      PER
□
HOUR
□
WEEK
□
MONTH
□
YEAR
GROUP BASIC TERM LIFE AND AD&D
□
I DO NOT APPLY
□
I DO APPLY  AMOUNT $
GROUP DEPENDENTS’ LIFE
□
I DO NOT APPLY
□
I DO APPLY
GROUP SUPPLEMENTAL LIFE
□
I DO NOT APPLY
□
I DO APPLY  EMPLOYEE ELECTION: $ SPOUSE ELECTION: $ CHILD ELECTION: $
SHORT-TERM DISABILITY
□
I DO NOT APPLY
□
I DO APPLY LONG-TERM DISABILITY
□
I DO NOT APPLY
□
I DO APPLY
PRIMARY
BENEFICIARY
FIRST NAME INITIAL LAST NAME RELATIONSHIP BIRTH DATE (MM/DD/YYYY) SOCIAL SECURITY #
CONTINGENT
BENEFICIARY
FIRST NAME INITIAL LAST NAME RELATIONSHIP BIRTH DATE (MM/DD/YYYY) SOCIAL SECURITY #
GROUP # SECTION # SOC. SEC. # ACCOUNT # CATEGORY
232320.0919
bcbsil.com 3
LAST NAME SOC. SEC. # GROUP #
SECTION 4 — COVERAGE OPTIONS
PLEASE COMPLETE ALL AREAS THAT APPLY
(IF YOU ARE ADDING AN ELIGIBLE MILITARY PERSONNEL DEPENDENT WHO IS OVER THE AGE LIMIT OF YOUR EMPLOYER’S PLAN,
COMPLETION OF A DEFENSE DEPARTMENT FORM 214 (DD 214) IS REQUIRED IN ADDITION TO THIS APPLICATION.)
EMPLOYEE/
ENROLLEE’S
NAME
PCP NAME
PCP #
IPA NAME
IPA #
WPHCP
NAME
WPHCP #
NEW PATIENT?
□
YES
□
NO
HMO OB/GYN NAME (OPTIONAL) HMO OB/GYN #
DEPENDENT’S NAME
□
HUSBAND
□
WIFE
□
DOMESTIC PARTNER
□
PARTY TO A CIVIL UNION
DEPENDENT’S PCP NAME PCP # NEW PATIENT?
□
YES
□
NO
IPA NAME
IPA #
WPHCP
NAME
WPHCP #
HMO OB/GYN
NAME (OPTIONAL)
HMO OB/GYN #
DEPENDENT’S
SOCIAL
SECURITY #
BIRTH DATE (MM/DD/YYYY) HOME ADDRESS (IF DIFFERENT) STREET/CITY/STATE/ZIP CODE
DEPENDENT’S NAME
□
SON 
□
DAUGHTER 
□
OTHER ELIGIBLE DEPENDENT
DEPENDENT’S PCP NAME PCP # NEW PATIENT?
□
YES
□
NO
BIRTH DATE (MM/DD/YYYY) HOME ADDRESS (IF DIFFERENT) STREET/CITY/STATE/ZIP CODE
IS THIS DEPENDENT A NATURAL CHILD, STEPCHILD,
FOSTER CHILD, ADOPTED CHILD OR A CHILD IN SUIT
FOR ADOPTION?
□
YES
□
NO
IF NOT YOUR ELIGIBLE NATURAL CHILD, STEPCHILD, FOSTER CHILD,
ADOPTED CHILD OR CHILD IN SUIT FOR ADOPTION, ARE YOU (OR YOUR
SPOUSE) RESPONSIBLE FOR THIS DEPENDENT?
□
YES
□
NO
DEPENDENT’S
SOCIAL
SECURITY #
IPA NAME
IPA #
HMO OB/GYN
NAME (OPTIONAL)
HMO OB/GYN #
DEPENDENT’S NAME
□
SON 
□
DAUGHTER 
□
OTHER ELIGIBLE DEPENDENT
DEPENDENT’S PCP NAME PCP # NEW PATIENT?
□
YES
□
NO
BIRTH DATE (MM/DD/YYYY) HOME ADDRESS (IF DIFFERENT) STREET/CITY/STATE/ZIP CODE
IS THIS DEPENDENT A NATURAL CHILD, STEPCHILD,
FOSTER CHILD, ADOPTED CHILD OR A CHILD IN SUIT
FOR ADOPTION?
□
YES
□
NO
IF NOT YOUR ELIGIBLE NATURAL CHILD, STEPCHILD, FOSTER CHILD,
ADOPTED CHILD OR CHILD IN SUIT FOR ADOPTION, ARE YOU (OR YOUR
SPOUSE) RESPONSIBLE FOR THIS DEPENDENT?
□
YES
□
NO
DEPENDENT’S
SOCIAL
SECURITY #
IPA NAME
IPA #
HMO OB/GYN
NAME (OPTIONAL)
HMO OB/GYN #
DEPENDENT’S NAME
□
SON 
□
DAUGHTER 
□
OTHER ELIGIBLE DEPENDENT
DEPENDENT’S PCP NAME PCP # NEW PATIENT?
□
YES
□
NO
BIRTH DATE (MM/DD/YYYY) HOME ADDRESS (IF DIFFERENT) STREET/CITY/STATE/ZIP CODE
IS THIS DEPENDENT A NATURAL CHILD,
STEPCHILD, FOSTER CHILD, ADOPTED CHILD
OR A CHILD IN SUIT FOR ADOPTION?
□
YES
□
NO
IF NOT YOUR ELIGIBLE NATURAL CHILD, STEPCHILD, FOSTER CHILD,
ADOPTED CHILD OR CHILD IN SUIT FOR ADOPTION, ARE YOU (OR YOUR
SPOUSE) RESPONSIBLE FOR THIS DEPENDENT?
□
YES
□
NO
DEPENDENT’S
SOCIAL
SECURITY #
IPA NAME
IPA #
HMO OB/GYN
NAME (OPTIONAL)
HMO OB/GYN #
SECTION 5 — DISABLED DEPENDENT PLEASE COMPLETE IF APPLICABLE
NAME OF DISABLED
DEPENDENT
NATURE OF
DISABILITY
NAME OF DISABLED
DEPENDENT
NATURE OF
DISABILITY
IF DISABLED CHILD IS OVER THE DEPENDENT AGE LIMIT OF YOUR EMPLOYER’S PLAN, PLEASE ATTACH A COMPLETED DISABLED DEPENDENT CERTIFICATION AND THE DISABLED DEPENDENT PHYSICIAN CERTIFICATION DOCUMENT.
SECTION 6 — OTHER COVERAGE INFORMATION PLEASE COMPLETE IF APPLICABLE
COMPLETE THIS SECTION ONLY IF YOU OR ANY OF YOUR DEPENDENTS HAVE OTHER HEALTH AND/OR DENTAL COVERAGE THAT WILL NOT BE CANCELED WHEN THE COVERAGE UNDER THIS APPLICATION
BECOMES EFFECTIVE. LIST NAMES OF EACH INDIVIDUAL COVERED:
GROUP COVERAGE
□
YES
□
NO
INDIVIDUAL COVERAGE
□
YES
□
NO
NAME AND ADDRESS OF OTHER INSURANCE CARRIER EFFECTIVE DATE (MM/DD/YYYY) TYPE OF POLICY
□
EMPLOYEE ONLY 
□
EMPLOYEE/SPOUSE
□
EMPLOYEE/CHILD(REN) 
□
FAMILY
NAME OF POLICYHOLDER BIRTH DATE (MM/DD/YYYY)
□
MALE
□
FEMALE
RELATIONSHIP TO APPLICANT
□
SELF
□
SPOUSE
□
DEPENDENT
EMPLOYER’S NAME EMPLOYMENT DATE (MM/DD/YYYY) HEALTH GROUP # HEALTH ID # DENTAL GROUP # DENTAL ID #
SECTION 7 — MEDICARE COVERAGE INFORMATION PLEASE COMPLETE IF APPLICABLE
NAME OF PERSON COVERED:
MEDICARE A (HOSPITAL) EFFECTIVE DATE: END DATE:
MEDICARE B (MEDICAL) EFFECTIVE DATE: END DATE:
MEDICARE D (DRUG) EFFECTIVE DATE: END DATE:
MEDICARE D (DRUG) CARRIER:
MEDICARE HIC # (FROM MEDICARE CARD)
PLEASE INDICATE REASON FOR MEDICARE ELIGIBILITY:
□
ENTITLED AGE 
□
ENTITLED DISABILITY 
□
END-STAGE RENAL DISEASE 
□
DISABILITY AND CURRENT RENAL DISEASE
NAME OF PERSON COVERED:
MEDICARE A (HOSPITAL) EFFECTIVE DATE: END DATE:
MEDICARE B (MEDICAL) EFFECTIVE DATE: END DATE:
MEDICARE D (DRUG) EFFECTIVE DATE: END DATE:
MEDICARE D (DRUG) CARRIER:
MEDICARE HIC # (FROM MEDICARE CARD)
PLEASE INDICATE REASON FOR MEDICARE ELIGIBILITY:
□
ENTITLED AGE 
□
ENTITLED DISABILITY 
□
END-STAGE RENAL DISEASE 
□
DISABILITY AND CURRENT RENAL DISEASE
232320.0919
bcbsil.com 4
SECTION 8 — DECLINATION OF COVERAGE PLEASE COMPLETE IF YOU ARE DECLINING COVERAGE
THIS IS TO CERTIFY THE AVAILABLE COVERAGE HAS BEEN EXPLAINED TO ME. I HAVE BEEN GIVEN THE OPPORTUNITY TO APPLY FOR THE COVERAGE OFFERED TO ME AND MY ELIGIBLE
DEPENDENTS AND HAVE VOLUNTARILY ELECTED TO DECLINE THE COVERAGE AS INDICATED BELOW. IF I DESIRE TO APPLY FOR COVERAGE AT A LATER DATE, I UNDERSTAND THERE MAY BE
A DELAY IN THE EFFECTIVE DATE OF THE COVERAGE.
NAME
□
EMPLOYEE REASON FOR DECLINING HEALTH:
□
OTHER GROUP HEALTH COVERAGE – CARRIER:
□
MEDICARE
□
MEDICAID
□
OTHER INDIVIDUAL HEALTH COVERAGE – CARRIER:
□
OTHER (EXPLAIN)
□
I AM NOT ENROLLED IN ANY HEALTH INSURANCE PLAN, BUT DO NOT WANT THIS COVERAGE
NAME
□
EMPLOYEE REASON FOR DECLINING DENTAL:
□
OTHER GROUP DENTAL COVERAGE
□
MEDICAID
□
INDIVIDUAL DENTAL COVERAGE
□
OTHER (EXPLAIN)
□
I AM NOT ENROLLED IN ANY DENTAL INSURANCE PLAN, BUT DO NOT WANT THIS COVERAGE
NAME
□
SPOUSE REASON FOR DECLINING:
□
OTHER GROUP HEALTH COVERAGE
□
MEDICAID
□
INDIVIDUAL HEALTH COVERAGE
□
OTHER (EXPLAIN)
□
I AM NOT ENROLLED IN ANY HEALTH INSURANCE PLAN, BUT DO NOT WANT THIS COVERAGE
NAME
□
DEPENDENT REASON FOR DECLINING:
□
OTHER GROUP HEALTH COVERAGE
□
MEDICAID
□
INDIVIDUAL HEALTH COVERAGE
□
OTHER (EXPLAIN)
□
I AM NOT ENROLLED IN ANY HEALTH INSURANCE PLAN, BUT DO NOT WANT THIS COVERAGE
NAME
□
DEPENDENT REASON FOR DECLINING:
□
OTHER GROUP HEALTH COVERAGE
□
MEDICAID
□
INDIVIDUAL HEALTH COVERAGE
□
OTHER (EXPLAIN)
□
I AM NOT ENROLLED IN ANY HEALTH INSURANCE PLAN, BUT DO NOT WANT THIS COVERAGE
SECTION 9 — COVERAGE CONDITIONS
• I am an employee or a retiree of the employer named in this enrollment application. I am eligible to participate in the coverage(s) aorded by my employer’s plan, which is either underwritten or
administered by Blue Cross and Blue Shield of Illinois or Dearborn Life Insurance Company. On behalf of myself and any dependents listed on this enrollment application, I apply for those coverage(s) for
which I am eligible. I state that the information given on this enrollment application is true and correct. I understand and agree that any intentional misrepresentation of a material fact made by me will
invalidate my coverage(s).
• Only those coverage(s) and amounts for which I am eligible will be available to me. I understand that if this enrollment application is accepted, the coverage(s) will become eective in accordance with the
provisions of the Contract(s)/Plan(s).
• I agree that my employer acts as my agent. I authorize necessary payroll deduction by my employer, if any, to cover the cost of my coverage(s).
• I understand that my participation in the coverage(s) is subject to any future amendment. I also understand that all notices given to my employer are applicable to me.
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
civil nes and criminal penalties.
APPLICANT’S SIGNATURE DATE
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Life, Disability, Critical Illness, Accident, and Vision products are issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Illinois is the trade name of Dearborn Life Insurance Company, an independent licensee of the Blue
Cross and Blue Shield Association. BLUE CROSS
®
, BLUE SHIELD
®
and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Medical, Pharmacy, and Dental products are offered by Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.
Health care coverage is important for everyone.
We provide free communication aids and services for anyone with a disability or who needs language assistance.
We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability.
To receive language or communication assistance free of charge, please call us at 855-710-6984.
If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to le a grievance.
Oce of Civil Rights Coordinator
300 E. Randolph St.
35th Floor
Chicago, Illinois 60601
Phone: 855-664-7270 (voicemail)
TTY/TDD: 855-661-6965
Fax: 855-661-6960
Email: CivilRightsCoordinator@hcsc.net
You may le a civil rights complaint with the U.S. Department of Health and Human Services, Oce for Civil Rights, at:
U.S. Dept. of Health & Human Services
200 Independence Avenue SW
Room 509F, HHH Building 1019
Washington, DC 20201
Phone: 800-368-1019
TTY/TDD: 800-537-7697
Fax: 855-661-6960
Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Complaint Forms: http://www.hhs.gov/ocr/oce/le/index.html
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Completed 22 December 2021

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