C15390-Hl Health & Life Employee Enrollment Application Form printable pdf download

Health & Life Employee Enrollment Application

Blue Shield plans for 51+ employees

Blue Shield of California and Blue Shield

of California Life & Health Insurance Company (Blue Shield Life)

Please note: Failure to complete this enrollment application legibly and completely may result in a delay in the enrollment process.

Reason for application:

c New hire

c Loss of coverage date ___ /___ /______

c Late enrollment

c Open enrollment

c Rehire date ___ /___ /______

c Other qualifying event type______________________

Date above event occurred ____/____/____

Section 1 – Important enrollment guidelines for Specialty Benefits coverage

Dental, vision, and life insurance coverage – An employee may enroll in a dental, vision, or life plan without enrolling in a health plan. In order for a dependent

to enroll in a dental or vision plan, the employee must be enrolled in the same dental or vision plan.

All of an employee’s dependents enrolled in the health plan will automatically be enrolled in the dependent basic life insurance plan if the employer offers

dependent basic life insurance coverage.

An employee must enroll in basic group term life/AD&D insurance to be eligible to enroll in supplemental life or supplemental AD&D insurance coverage.

The employee may also enroll their spouse/domestic partner and child (ren) in supplemental life or supplemental AD&D insurance only if supplemental

dependent life or AD&D insurance is offered by the employer.

Evidence of insurability: For all basic group term life/AD&D insurance coverage, if an employer contributes 100% of the premium, then 100% of eligible

employees must enroll and evidence of insurability is not required Evidence of insurability is required for basic group term life/AD&D coverage when the

employee is a late enrollee or if the employer contributes less than 100% of the premium. Supplemental coverage is always subject to evidence of insurability.

Section 2 – Plan(s)

Select and fill in plan name(s), if applicable.

Plans for 51+ employees

Medical benefits with ABHP (account-based

Specialty Benefits

health plan) plan options:

Medical benefits without ABHP (account-

c Basic group term life/AD&D insurance

based health plan) plan options:

c Dependent basic life insurance

Access+ HMO: c HRA c HIA c FSA

c Supplemental life insurance

c Access+ HMO ____________________

Local Access+ HMO: c HRA c HIA c FSA

c Supplemental AD&D insurance

c Access+ HMO SaveNet _____________

Shield PPO: c HRA c HIA c FSA

c Dental PPO ________________________

c Local Access+ HMO ________________

c Dental INO

Shield PPO Savings Plus: c HRA c HIA

________________________

c Added Advantage POS ______________

c Dental HMO _______________________

c FSA c HSA c LFSA

c Active Choice

____________________

c Vision ____________________________

c Shield PPO ______________________

51-100 Small Group Transition plans:

c Other _____________________________

c Shield Spectrum PPO _______________

c HMO c PPO c PPO for HSA

c Shield PPO Savings Plus

____________

1 Underwritten by Blue Shield of California Life & Health

ABHP benefit options for above plans:

c Other __________________________

Insurance Company (Blue Shield Life).

For HMO: c HRA c HIA c FSA

2 Shield PPO Savings Plus are HSA-eligible high-deductible

health plans.

For PPO: c HRA c HIA c FSA

Note: Blue Shield does not offer tax advice, nor do we offer

For Shield PPO Savings Plus for HSA: c HRA

HSAs, HRAs, HIAs, and FSAs.

c HIA c FSA c LFSA

Internal use only. Do not write in this section and skip to Section 3.

Department code

Group number

Effective date

_____/______/_____________

Section 3 – Employee information

Social Security number

Employer (group) name

Last name

First name

Employment status:

Job title/classification

Date of hire: _____ /_____ /__________

c Full time

c Part time

c Retiree

Home address (street, city, state, ZIP)

Basic group term life/AD&D insurance amount:

Mailing address (if different from home address)

Supp. life insurance

Supp. AD&D insurance

amount:

Home phone number

Email address

How would you prefer we contact you?

c Email c Standard mail c Telephone

C15390-HL

Employee enrollment application (for 51+ employees)

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C15390-Hl Health & Life Employee Enrollment Application Form

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