Application To Reapply For Coverage Page 2
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4Application to Reapply for Health Insurance Coverage
Essential Blue Freedom
(For Current Policyholders Only)
Return To: Arkansas Blue Cross and Blue Shield, Attn: Individual Underwriting, P.O. Box 2181,
Little Rock, AR 72203-2181 or Fax to: 501-378-3752
1 CURRENT POLICYHOLDER INFORMATION
Member ID
Group Number
Date of Birth
:___________________________
:_____________________
:_____/____/_____
First Name
M.I
Last Name:
: ________________________________
.:______
___________________________________
2 CONTACT INFORMATION
How do you prefer we
Primary Phone Number
Alternate Phone Number
E-mail Address
(
)
(
)
communicate with you?
o E-mail
o Phone
3 ADDRESS INFORMATION
Residential Address:
Street__________________________________________________________________________
City________________________________________________ State_________ Zip___________
Mailing Address:
Street__________________________________________________________________________
City________________________________________________ State_________ Zip___________
Billing Address:
Street__________________________________________________________________________
City________________________________________________ State_________ Zip___________
4 MEDICAL QUESTIONNAIRE
You must answer “Yes” or “No” to every question below for each person on your Essential Blue Freedom policy. If you
cannot answer “Yes” to the blood pressure, cholesterol or glucose questions, you still may be eligible for a new policy. For
any “No” answer, please provide the actual value in the space provided. You may still be approved, however, your
policy will be subject to review.
Blood
Cholesterol
Any tobacco
2
1
Pressure
less than 240
Glucose/A1c
use in the past
3
First Name
Last Name
M.I.
Height
Weight
under 160/100?
mg/dl?
less than 6.1%?
year?
oYes oNo
oYes oNo
oYes oNo
____ ft.
oYes oNo
____ lbs.
____ in.
oYes oNo
oYes oNo
oYes oNo
____ ft.
oYes oNo
____ in.
____ lbs.
oYes oNo
oYes oNo
oYes oNo
____ ft.
oYes oNo
____ lbs.
____ in.
oYes oNo
oYes oNo
oYes oNo
____ ft.
oYes oNo
____ in.
____ lbs.
oYes oNo
oYes oNo
oYes oNo
____ ft.
oYes oNo
____ in.
____ lbs.
oYes oNo
oYes oNo
oYes oNo
____ ft.
oYes oNo
____ in.
____ lbs.
Healthy blood pressure is a reading under 160/100
1
Healthy total cholesterol level is under 240 mg/dl
2
Healthy blood sugar is a glycohemoglobin A1c below 6.1%
3
Page 1
Form No. EBF Reapply DR (06/14)
(Continued on page 2)
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