Form Bcbs 16628 - Enrollment Form
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1
2Enrollment Form
PLEASE PRINT ALL INFORMATION
Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company,
is an independent licensee of the Blue Cross and Blue Shield Association.
To Be Completed By Human Resources
Group Number
Effective Date
Employee Type:
Active
COBRA
Retired
Decline
(If declining coverage, please complete page 2.)
Enrollment:
(check event and give event date;
Adoption
Birth
Court Order
Custody/Guardianship
Event Date:
New Hire
Open
Qualifying Event
attach copies of legal documents for adoption,
Divorce
Group Transfer
Loss of Coverage
custody, guardianship, court order, MDHS, divorce)
Marriage
New Hire
MDHS
Employee Occupation:
Social Security Number
First Name
M.I.
Last Name:
Phone Number:
Mailing/Street Address
Apt./Ste
City
State
Zip Code
Marital Status:
Sex:
Birth Date:
Hire Date:
Medical Coverage Type:
Employee
Dental Coverage Type:
Employee
Married
Single
Other
Male
Female
Family
Employee + Children
Family
Employee + Children
Employee + Spouse
Employee + Spouse
CREDITABLE COVERAGE
OTHER INSURANCE INFORMATION
Did you have prior coverage?
Yes
No
Are you covered by any other insurance?
Yes
No
If yes, enter From and Through dates.
If yes, complete “Other Coverage” form.
From:
Through:
DATE OF BIRTH
INDICATE YES OR NO FOR EACH ITEM BELOW
FIRST NAME
RELATIONSHIP
FULL
SOCIAL SECURITY
SEX
TO
MO
DAY YEAR
FULL-TIME
COBRA
OTHER HEALTH COVERAGE
CREDITABLE COVERAGE
NUMBER
M/F
NAME
STUDENT
PARTICIPANT
IF YES, COMPLETE
IF YES, PROVIDE FROM AND THROUGH DATES.
LAST NAME
EMPLOYEE
®
IF AGE 19 - 25
“OTHER COVERAGE”
FROM
THROUGH
FORM.
Husband/Wife
Children
Name of school for those age 19 and over _______________________________________________________________________________________________________________________________________
For myself and dependent’s named above, I apply for health insurance coverage available through my Employer. I
represent that all the information provided by me in this Enrollment Form is complete and accurate. I certify that I have
AUTHORIZATION (EMPLOYEE SIGNATURE)
DATE
read the above statements or that they have been read to me and that they are true and complete to the best of my
MO.
DAY
YR.
knowledge. I understand that any misrepresentation of this information on my part may be used by my Employer to
reduce or deny a claim for benefits as well as result in disciplinary action. I also agree to pay the appropriate fees for
the coverage and authorize my Employer to deduct that amount from my wages and salary. Last, I acknowledge that
the health insurance applied for is subject to all exclusions and limitations set forth in the Master Group Contract.
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