Please be sure ALL information below is complete to avoid delays in processing.
Please print clearly using blue or black ink, or type information.
Section 1 Employer Information (To be completed by plan administrator.)
Group name Eective date
Date of hire
Group number Dept. number
Choose one: or Add dependent(s)
c Open enrollment c Spouse
New hire c Dependent
Loss of coverage (Certiﬁcate Date of event (mm/dd/yyyy) ____________
of Creditable Coverage required)
( Must add within 30 days of marriage,
birth, or adoption of dependent.)
Section 2 Employee Information
Last name Sux First name M.I.
Home address (street/apartment number) City/town State ZIP code
Mailing address (street/apartment number, city/town, state, ZIP code—if dierent from above)
Date of birth
c M c F
Social Security number
What is your primary spoken
Home phone number Cell phone number
Marital status (please check one)
c Single c Married c Divorced c Civil union c Common law c Domestic partner
Race (please check one)
cPrefer not to answer
c Hispanic or Latino
c American Indian or Alaska Native c Asian c Black or African American
c Native Hawaiian or other Paciﬁc Islander c White cMultiracial
Primary care provider (PCP) name, street, city/town, state, and ZIP code (Required if electing BlueCHiP Flex or Blue Choice)
You must select a PCP for yourself and anyone on your plan, otherwise your enrollment may be delayed and benefits may be reduced.
Are you a current patient of the PCP listed above?
c Yes c No
Large Group Member Application for
Health, Dental, and Vision Insurance
c Other ___________________
* Social Security number is required in order to comply with the reporting requirements of the Mandatory Insurance Reporting Law. See
Group APP (08/17)