Bcbs Membership Application Form
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1MEMBERSHIP APPLICATION
BLUE CROSS
®
AND BLUE SHIELD
®
OF SOUTH CAROLINA, An independent licensee of the Blue Cross and Blue Shield Association
COMPANION HEALTHCARE, A wholly-owned subsidiary of Blue Cross and Blue Shield of South Carolina, An independent licensee of the Blue Cross and Blue Shield Association
COMPANION LIFE INSURANCE COMPANY, A wholly-owned subsidiary of Blue Cross and Blue Shield of South Carolina.
1. Please indicate reason for Application:
New Subscriber(s)
Coverage Change
Cancel
Miscellaneous
2. EFFECTIVE DATE OF ACTION REQUESTED:
DATE OF HIRE:
ELIGIBILITY DATE:
MONTH
DAY
YEAR
MONTH
DAY
YEAR
MONTH
DAY
YEAR
x
3. Type Contract:
Preferred Blue
IDENTIFICATION
4. Employee — Last Name
First
Initial
Home Telephone No.
5. Social Security No.
6. Mailing Address (Street or P.O. Box)
(City)
(State)
(Zip Code)
(County Code - see back)
7. Name of Employer
8. Blue Cross Group Number
9. Dept. No.
10. Payroll No.
Presbyterian College
–
–
–
REASON FOR COVERAGE CHANGE
11. Check appropriate reason; give occurrence date in Block 13:
12. Name of spouse to be
13. Occurrence Date or
excluded from coverage if
Left Employment Date
A
Birth or Adoption
C
Divorce
F
Attained Reduction Age
applicable
Mo.
Day
Yr.
B
Death (Name:
)
D
Marriage
E
Other – Explain:
TYPE MEMBERSHIP AND COVERAGE INFORMATION
14. Check type membership for each coverage desired.
.
S – Single
F – Family
F – Employee/Children
8 – Employee/Spouse
Birthdate
15. List All Family Members Covered or Affected By a Change
Last Name
First
Initial
Sex
Mo. Day Yr.
YOURSELF:
Spouse
Social Security No.
Child
Social Security No.
Child
Social Security No.
Child
Social Security No.
OTHER INSURANCE INFORMATION
16. Do you or does any member of your family have other health, dental or drug coverage, Federal Employees’ Program (FEP) or Medicare?
YES
NO
If Yes:
MEDICARE A
Effective Date
MEDICARE B
Effective Date
A. Family Member’s Name
and Social Security No.
B. Name of Insurance Co.
Policy No.
Effective Date
C. Family Member’s Employer
D. List Names of Covered Persons 1
2
3
4
E. Please circle each type of service covered by this policy: Hospital, Physician/Medical, Prescription Drugs, Dental, Vision
EMPLOYEE CERTIFICATION
17. Employee Certification –
I HAVE READ AND UNDERSTAND EACH AND EVERY PART OF THIS ENROLLMENT APPLICATION.
Date:
Signature:
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