Form 280.277 - Bcbs Vermont Medigap Blue Application And Change Form
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1
2Please send this fully completed form to:
Vermont Medigap Blue
SM
Blue Cross and Blue Shield of Vermont
P.O. Box 186
Application and Change Form
Montpelier, VT 05601-0186
Section 1: Subscriber Coverage Information
Name
Social Security No.
Date of Birth
E-mail Address
Last Name
First Name
M.l.
Physical Address
Desired Coverage
Home Phone No.
(required)
Plan A
Plan F
Street Address
Plan C
Plan N
Daytime Phone No.
Plan D
City
State
ZIP Code
Mailing Address
Marital Status
Gender
Male
Married/Party to a Civil Union
Street Address
Single
Female
Widowed/Divorced
City
State
ZIP Code
Section 2: Reason for Form (check applicable boxes and indicate dates as month/day/year)
Application
Change
Cancellation
Please provide copy of your Medicare Card
Name
Voluntary cancel
Turning/turned 65
Address
Obtained other coverage
New disability
Death
Date of change ___/___/___
Other new subscriber
Date of cancellation ___/___/___
(please see Section 3 below)
Eff ective Date ___/___/___
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 benefi ts. I certify that (please check one):
I will soon turn 65, will soon retire or I turned 65 years of age
I lost, or will lose, coverage through my spouse/party to a civil union
within the last six months.
because he or she is retiring.
I retired in the last 63 days and therefore lost
I lost/dropped group coverage
my employer-sponsored health coverage.
Date of coverage loss: _____________________
Retirement date: ________________________
I am currently receiving social security disability payments and I
I involuntarily lost Medicare-supplemental or Medicare
became eligible for Medicare within the last six months because I
Advantage coverage within the last 63 days.
have a total disability.
Date of coverage loss: _____________________
Date of Medicare eligibility determination: _________
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 for the fi rst month's premium (from a non-business account made out to Blue Cross and Blue Shield of Vermont) and
a copy of your Medicare card.
Subscriber’s Signature: ______________________________________________________
Date: _____ /_____ /______
280.277 (11/2015)
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