Form 280.291 - Bcbs Vermontblue 65 Application And Change Form

ADVERTISEMENT

Please send this form to:
VermontBlue 65
SM
Blue Cross and Blue Shield of Vermont
 Group #__________
P.O. Box 186
 Individual
Application and Change Form
Montpelier, VT 05601-0186
Section 1: Subscriber Coverage Information
Name
Social Security No.
Date of Birth
Cell Phone
Home Phone No.
Last Name
First Name
M.l.
Physical Address
Desired Coverage
Effective Date
(required)
 Plan A
Street Address
 Plan C
City
State
ZIP Code
Mailing Address
Marital Status
Gender
(if different)
 Married/
 Male
Street Address
Party to a Civil Union
 Female
 Single
 Widowed/Divorced
City
State
ZIP Code
E-mail Address
Employment Status:  Active  Retired
Section 2: Reason for Form (check applicable boxes and indicate dates as month/day/year)
Application
Change
Cancellation
 Turning/turned 65*
 Voluntary cancel
 Name
 Transfer from other BCBS Plan*
 Obtained other coverage
 Address
 Other—new subscriber
 Death
 New disability*
Date of the above ___/___/___
Date of change ___/___/___
Date of cancellation ___/___/___
Section 3: Enrollment & Eligibility
By signing this form, I attest that I do not have other Medicare Supplemental Coverage and
that when this coverage is in force, I will not have other coverage that would duplicate its benefits.
 Date of retirement: _____________________
* If you have just retired or just turned 65, you may qualify for our Vermont Medigap Blue supplemental product.
Please call (802) 371‑3299 to explore this option.
 By signing, I hereby attest that I have read the statements and answered the questions on the back of this form.
Please enclose a check (made out to Blue Cross and Blue Shield of Vermont) and a copy of your Medicare card.
Subscriber’s Signature: __________________________________________________
Date: ___ /____ /______
Be sure to read the information on the back of this form and answer the questions that follow.
280.291 (10/2011)

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form 280.277 - Bcbs Vermont Medigap Blue Application And Change Form Form 280.277 - Bcbs Vermont Medigap Blue Application And Change Form Business
Form 10-20 - Dental Application And Change Form - Bcbs Form Form 10-20 - Dental Application And Change Form - Bcbs Form Business
Form Ddp-692 - Application And Change Form For Individual & Family Dental Insurance Form Ddp-692 - Application And Change Form For Individual & Family Dental Insurance Business
Medical And/or Dental Application And Change Form Medical And/or Dental Application And Change Form Business
Life Long Term Disability Ltd And Or Short Term Disability Std Application And Change Form Life Long Term Disability Ltd And Or Short Term Disability Std Application And Change Form Legal
Enrollment Application And Change Of Information Form Enrollment Application And Change Of Information Form Business
Dental Application And Change Form Dental Application And Change Form Medical
Form De1 - Application To Have Deposit Interest Paid Without Deduction Of Dirt Where Applicant And/or Spouse Or Civil Partner Is Aged 65 Or Over - 2017 Form De1 - Application To Have Deposit Interest Paid Without Deduction Of Dirt Where Applicant And/or Spouse Or Civil Partner Is Aged 65 Or Over - 2017 Legal
Form De1 - Application To Have Deposit Interest Paid Without Deduction Of Dirt Where Applicant And/or Spouse Or Civil Partner Is Aged 65 Or Over Form De1 - Application To Have Deposit Interest Paid Without Deduction Of Dirt Where Applicant And/or Spouse Or Civil Partner Is Aged 65 Or Over Legal
Form 211-65 - Application For Refund For Persons 65 Years Or Over - 2006 Form 211-65 - Application For Refund For Persons 65 Years Or Over - 2006 Business

Related Categories

Parent category: Business
Download
Go
Page of 2