Form 10-77crf - Change Request Form
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1ID #
Arkansas Blue Cross and Blue Shield
Health Advantage
ATTN: Customer Accounts 2 North
ATTN: Customer Accounts
Group
P O Box 2181
P O Box 8069
Name:
Little Rock, AR 72203-9974
Little Rock, AR 72203-8069
Fax 501-301-6869
Fax 501-378-3248
Group #:
CHANGE REQUEST FORM
First Name
M.I.
Last Name
Social Security No.
Date of Birth
∕
∕
Home Address
Phone #
Check if Changed
Check if Changed
Change coverage as indicated below:
Name Change: Current Name :
New Name :
∕
∕
Cancel Employee:
Left Job
Other: Reason
Cancel Coverage
Has the Employee being terminated contributed to the premium past the termination date requested?
Yes
No
Cancel coverage for a Family Member :
Last Month employee contributed premium:
1. Member Name:
Termination
Last Month employee
∕
∕
Date:
contributed premium:
2. Member Name:
Termination
Last Month employee
∕
∕
Date:
contributed premium:
Has the Member being terminated contributed to the premium past the termination date requested?
Yes
No
USAble Life Insurance – Beneficiary Change
USAble Life is an independent company and operates separately from Arkansas Blue Cross and Blue Shield and Health Advantage. USAble Life does not
sell or service Arkansas Blue Cross and Blue Shield or Health Advantage products. USAble Life is solely responsible for life insurance.
I hereby designate the beneficiary or beneficiaries listed below under this certificate and revoke the appointment of any existing
beneficiary.
First Name
MI
Last Name
Date of Birth
Relationship
∕
∕
The following changes apply to Health Advantage contracts only:
Select or Change Primary Care Physician (PCP)
Member Name:
PCP Name:
PCP # :
Clinic Name
Clinic Address:
In signing below, I represent that the statements and answers given in this application are true, complete and correctly
recorded. I understand that any performance of any act or practice constituting fraud or intentional misrepresentation of
material fact may result in cancellation of any coverage issued in reliance thereon, and that Arkansas Blue Cross and Blue
Shield, Health Advantage, and/or USAble Life may recover monies and damages incidental and consequential to that result.
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
∕
∕
Employee Signature
Date
∕
∕
Group Administrator Signature
Date
Form No. 10-77CRF R08/11
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