Form F8046r05 - Bcbs Enrollment Change Form

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A. GROUP EMPLOYEE ENROLLMENT AND CHANGE FORM –
INSTRUCTIONS FOR CHANGES ON PAGE 2
Employee’s Last name
First name
M.I.
Date of Birth
Social Security Number
Home phone
(
)
Employee’s Home address
Street
City
State
Zip code
Work phone
(
)
B. LIST ALL INDIVIDUALS TO BE ADDED OR CANCELLED –
COMPLETE ALL THAT APPLY
(use extra paper if necessary)
Relation
Last name
First name
M.I.
Cancel
Add/
Sex
Marital
Social Security #
Birth Date
Primary Care
Full-time
(Circle)
Eff. Date
Cancel (Circle)
status
(Mo. Day Yr.)
Clinic #
Student
Add
Married
Yes
M / F
Self
Cancel
Single
No
Add
Married
Yes
M / F
Spouse
Cancel
Single
No
Child
Add
Married
Yes
M / F
Stepchild
Cancel
Single
No
Child
Add
Married
Yes
M / F
Stepchild
Cancel
Single
No
Child
Add
Married
Yes
M / F
Stepchild
Cancel
Single
No
For full-time student
Anticipated graduation date:
list school:
C. BENEFIT SELECTION –
CHECK APPROPRIATE BOXES TO ELECT OR WAIVE COVERAGE
Elect or
Waive Health (self)
Elect or
Waive Supplemental Life (Benefit chosen $_________________ )
Elect or
Waive Health (dependents)
Elect or
Waive STD
Elect or
Waive LTD
Elect or
Waive Dental (self)
Elect or
Waive Life/AD&D (self)
Elect or
Waive Dental (dependents)
Elect or
Waive Life/AD&D (self with dependent life coverage)
Health plan product name:
Dental plan product name:
Beneficiary
Full Name
Date of Birth
Relationship
Primary
Contingent
X
Month
Day
Year
I UNDERSTAND THAT PROVIDING FALSE INFORMATION IN THIS APPLICATION
MAY RESULT IN THE DENIAL OF CLAIM(S) OR CANCELLATION OF COVERAGE.
Signature of employee
Date signed
D. THIS PART TO BE COMPLETED BY EMPLOYER
Employee date of employment (MM/DD/YY):
Employee occupation:
Hours worked per week:
Monthly salary
(Complete only if applying for salary-based benefits)
$ ______________________
Indicate the reason employee is enrolling for coverage:
New employee
Rehire
___________
New group
(length of layoff)
Return from leave of absence
____________________________________________
(length of absence)
Previously waived coverage
Change from part-time to full-time
Certificate of coverage termination
Other ____________________________________________
Date of event: ______________________________
Group numbers:
Health _______________
Dental _______________
Life _______________
STD _______________
LTD _______________
Department number __________________
Class __________________________________________________
I certify the above information to be true and correct.
Signature _________________________________________________________ ___________________ Date ___________________________________
Employer name
Telephone number
Fax number
(
)
(
)
1
F8046R05 (9/07)

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