Employee Application Form - Blue Cross Blue Shield Of Arizona

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EMPLOYEE APPLICATION

EFFECTIVE DATE OF COVERAGE:

MEDICAL PLAN TYPE

MEDICAL COVERAGE

ARE YOU DECLINING COVERAGE

NEW GROUP

EMPLOYEE ONLY

FOR:

PPO

OPEN

EMPLOYEE & SPOUSE

SELF?

PPO HSA QUALIFIED

ENROLLMENT

_____________

EMPLOYEE & CHILDREN

HMO

SPOUSE?

OPTION

FAMILY

OTHER

DEPENDENT(S)?

BCBSAZ ID NUMBER ( existing member )

DENTAL COVERAGE

BLUEALLIANCE*

If yes, include the appropriate reason

EMPLOYEE ONLY

code(s) in Section II below. (A list of

EMPLOYEE & SPOUSE

DENTAL

_____________

reason codes is found near the bottom

EMPLOYEE & CHILDREN

EMPLOYEE NUMBER (employer use only)

DENTAL

OPTION

of page 2.)

FAMILY

*MOST IN-NETWORK ARIZONA PROVIDERS FOR THIS LOCAL NETWORK PLAN ARE LOCATED ONLY IN MARICOPA COUNTY.

OPT FOR A FLEXIBLE SPENDING ACCOUNT (FSA) AVAILABLE FROM HEALTH EQUITY

I want a healthcare FSA

I want a dependent care FSA

I do not want an FSA

HealthEquity is an independent company, contracted with BCBSAZ to administer FSAs for group benefit plans.

SECTION I – INFORMATION REGARDING YOUR EMPLOYER

LOCATION

GROUP NUMBER

JOB CLASSIFICATION

EMPLOYER NAME

OTHER (SEE EMPLOYER)

SECTION II – INFORMATION REGARDING THE EMPLOYEE

SOCIAL SECURITY NUMBER

LAST NAME

FIRST NAME

M.I.

MARK ONE:

Required. See (O) on page 2.

ADD

CHANGE

WAIVER

PHYSICAL ADDRESS (NUMBER, STREET & APARTMENT NO.)

STATE

ZIP + FOUR

CITY

(SEE

CODE

_____

BACK)

STATE

ZIP + FOUR

MAILING ADDRESS

CITY

DATE OF BIRTH (MM/DD/YYYY)

MALE FEMALE MARRIED SINGLE DATE OF MARRIAGE (MM/DD/YYYY)

WORK TELEPHONE (AREA CODE AND NO.)

HOME TELEPHONE (AREA CODE AND NO.)

See page 2 (N) regarding

EMAIL ADDRESS

e-mail authorization

Will you or your dependents be covered by other health insurance in addition to BCBSAZ?

YES

OTHER COVERAGE

INFORMATION:

If yes, please complete the other coverage information below.

OTHER HEALTH PLAN COVERAGE NAME

CARRIER PHONE NO. (AREA CODE & NO.)

POLICY HOLDER LAST NAME

ID/SOCIAL SECURITY NUMBER

GROUP/POLICY NO.

EFFECTIVE DATE (MM/DD/YYYY)

MEDICARE CARD NO.

PART A EFFECTIVE DATE

PART B EFFECTIVE DATE

Complete the following for all dependents. If you have more than 3 dependents, complete a separate form.

New employees: Complete the following information for each eligible dependent including those declining or waiving coverage.

Enrolled employees: to add or remove dependent(s) or change coverage options, only include the persons affected by the change.

MARK ONE:

LAST NAME

FIRST NAME

M.I.

ADD

DELETE

RELATIONSHIP

DATE OF BIRTH (MM/DD/YYYY)

MALE

FEMALE

CHANGE

SOCIAL SECURITY NUMBER

Required. See (O) on page 2

WAIVER

(SEE

CODE

_____

BACK)

OTHER HEALTH PLAN COVERAGE NAME

CARRIER PHONE NO. (AREA CODE & NO.)

POLICY HOLDER LAST NAME

IDENTIFICATION NUMBER

GROUP/POLICY NO.

EFFECTIVE DATE (MM/DD/YYYY)

MEDICARE CARD NO.

PART A EFFECTIVE DATE

PART B EFFECTIVE DATE

MARK ONE:

LAST NAME

FIRST NAME

M.I.

ADD

DELETE

RELATIONSHIP

DATE OF BIRTH (MM/DD/YYYY)

MALE

FEMALE

CHANGE

SOCIAL SECURITY NUMBER

Required. See (O) on page 2

WAIVER

(SEE

CODE

_____

BACK)

OTHER HEALTH PLAN COVERAGE NAME

CARRIER PHONE NO. (AREA CODE & NO.)

POLICY HOLDER LAST NAME

IDENTIFICATION NUMBER

MEDICARE CARD NO.

GROUP/POLICY NO.

EFFECTIVE DATE (MM/DD/YYYY)

PART A EFFECTIVE DATE

PART B EFFECTIVE DATE

MARK ONE:

LAST NAME

FIRST NAME

M.I.

ADD

DELETE

MALE

FEMALE

RELATIONSHIP

SOCIAL SECURITY NUMBER

DATE OF BIRTH (MM/DD/YYYY)

CHANGE

Required. See (O) on page 2

WAIVER

(SEE

CODE

_____

BACK)

OTHER HEALTH PLAN COVERAGE NAME

POLICY HOLDER LAST NAME

IDENTIFICATION NUMBER

CARRIER PHONE NO. (AREA CODE & NO.)

GROUP/POLICY NO.

EFFECTIVE DATE (MM/DD/YYYY)

MEDICARE CARD NO.

PART A EFFECTIVE DATE

PART B EFFECTIVE DATE

I certify to all of the following on behalf of myself and the persons listed on this application as eligible dependents: (1) I have read this entire form; (2) I understand and agree to its terms; (3) I apply for

enrollment and/or waive group benefits as indicated on this form, subject to all terms and conditions of the coverage, as offered by my employer; (4) the information I have provided is accurate and complete,

and I understand that provision of false information may result in fines and criminal penalties; and (5) if any part of any premium for coverage or other financial services will be paid through payroll deduction,

I authorize my employer to periodically deduct from my wages, and remit amounts necessary to continue the coverage and any services.

EMPLOYEE’S SIGNATURE

DATE

Page 1

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