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and Blue Shield Association
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Employee's Last name First name M.
Homephone Work phone
Employee's Home address Street City State Zip code
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Last name First name M.I. Add/ Sex Marital Social Security# Relation Birth Date Primary Care Full-time
Cancel (Circle) status (Circle) (Mo.Day Yr.) Clinic# Student
❑ Add M/F ❑ Married If ❑ Yes
❑ Cancel ❑ Single ❑ No
❑ Add M/F ❑ Married Spouse
❑ Yes
❑ Cancel ❑ Single p ❑ No
❑ Add M F ❑ Married Child ❑ Yes
❑ Cancel ❑ Single Stepchild ❑ No
❑ Add M/F El Married Child ❑ Yes
❑ Cancel ❑ Single Stepchild ❑ No
❑ Add M/F ❑ Married Child ❑ Yes
��ppFI ❑ Cancel ❑ Single Stepchild ❑ No
❑ Elect or ❑ Waive Health (self) ❑ Elect or ❑ Waive Supplemental Life
❑ Elect or ❑ Waive Health (self/dependents) (Benefit chosen $
❑ Elect or ❑ Waive Dental (self) ❑ Elect or ❑ Waive STD
❑ Elect or ❑ Waive Dental (self/dependents) ❑ Elect or ❑ Waive LTD
❑ Elect or ❑ Waive Life/AD&D (self)
❑ Elect or ❑ Waive Life/AD&D (self/dependents)
Health plan product name: Dental plan product name:
If applying for life benefits,please indicate Beneficiary name and Relation to self:
Primary Beneficiary name Relation to self
Contingent Beneficiary name Month Day Year
I UNDERSTAND THAT PROVIDING FALSE INFORMATION IN THIS APPLICATION X
MAY RESULT IN THE DENIAL OF CLAIM(S)OR CANCELLATION OF COVERAGE. Signature of employee Date signed
D. THIS PART TO BE COMPLETED BY EMPLOYER
Employee date of employment(MM/DD/YY): Employee occupation: Hours worked per week:
Monthly salary (Complete only if applying for salary based benefits) $
Indicate the reason employee is enrolling for coverage:
❑ New employee ❑ Rehire (length of layoff) ❑ New group
❑ Return from leave of absence (length of absence)
❑ Previously waived coverage ❑ Change from part-time to full-time
❑ Certificate of coverage termination ❑ Other
Date of event:
Group numbers:
Health Dental Life STD LTD
Department number Class
I certify the above information to be true and correct.
Signature Date
Employer name Telephone number Fax number
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Do you or any family member listed on this application, have any current health coverage or had previous health coverage
within the last 63 days? ❑Yes ❑ No If YES you must fully complete the following section
If you or any family member applying for this coverage is currently covered by Blue Cross and Blue Shield of Minnesota,
Blue Plus, MII Life, Inc or Delta Dental, do you want that coverage canceled? ❑Yes ❑ No
If YES, provide the individual's name, identification number, group number and cancellation date:
Starting with the employee, list each family member applying for our coverage and include information for all current and
previous coverage in effect during the last 18 months. Make sure to include information for other Blue Cross and Blue Shield of
Minnesota coverage:
Family Member Insurance Company Date Coverage Date Coverage Reason for
Name (name and policy number) Started Ended Termination
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Are you or your spouse covered by Medicare Part A (Hospital) and Part B (Medical)? ❑Yes (complete section below) ❑ No
Employee:
Effective Date Part Al I 1 1 I 1 I Effective Date Part B I I I I Medicare Claim Number 11 -I 1 -I 1 1 I -LJ
Eligibility reason for Medicare: ❑Age ❑ Disability ❑ End-Stage Renal Disease ❑ Disability & End-Stage Renal Disease
Spouse:
Effective Date Part Al ( I 1 I 1 1 Effective Date Part B 1 1 I ( 1 Medicare Claim Number 11 1 -I -I 1 1 I -LJ
Eligibility reason for Medicare: ❑Age ❑ Disability ❑ End-Stage Renal Disease ❑ Disability & End-Stage Renal Disease
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Adding dependents: Date of event Deleting dependents: Date of event
❑ Birth/adoption ❑ Divorce
❑ Court Order ❑ Other(explain)
❑ Full-time student School
❑ Marriage County
❑ Other Details
Loss of prior health and/or dental coverage: ❑ Address change
Did you lose health coverage, dental coverage or both? ❑ Primary care clinic change
Date of event ❑ Phone number change
❑ Other coverage voluntarily terminated ❑ Name change
❑ Group continuation (COBRA) period exhausted Previous
❑ Employer contribution for coverage terminated List new name in Section A
❑ Coverage terminated due to loss of eligibility Reason
ENROLLMENT CHANGE FORM SHOULD BE SENT TO: Blue Cross and Blue Shield of Minnesota and Blue Plus
P.O. Box 64024
St. Paul, Minnesota
55164-0024