Form C12914 - Employee Enrollment Application - Blue Shield Of California

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Employee Enrollment Application

Blue Shield plans for groups with 2-50 eligible employees

Please fill in all fields, required fields are outlined in rose.

Effective January 1, 2013

Blue Shield of California and Blue Shield of California Life & Health Insurance Company (Blue Shield Life)

* Please note: It is very important that all questions be answered. Missing information may delay processing.

Reason for application:

 New group enrollment

 Family addition

 Special enrollment period

 New hire (date) __________________

 Open enrollment

Qualifying event type ______________________________

 Re-hire (date) __________________

 Late enrollment

Date above event occurred _______________

Section 1 – Plan selection –

Select and/or ﬁll in plan name(s) as appropriate.

Medical Beneﬁt Plans:

Optional beneﬁts:

Premier PPO

 5  15  25  35  45

Check plan(s) and ﬁll in names as appropriate

1,2

Enhanced PPO

 15  25  35  45

 Dental PPO plan __________________

1,2

Base PPO

 30  40  50

 Dental INO

plan __________________

1,2

Shield Spectrum PPO

 750 Value  1000 Value  1500 Value  2500 Value

 Dental HMO plan __________________

SM 1,2

Simple Savings

 2500/5000  3500/7000  4500/9000  5500/11000

 Vision plan __________________________

1,2,3

Access+ HMO Premier  15  25  35  45

 Life/ AD&D Insurance/Amt ______________________

Access+ HMO Enhanced  15  25  35  45

 Dependent Life Insurance/Amt. (max $5,000) __________

Local Access+ HMO Premier  15  25  35  45

 Other _________________

Local Access+ HMO Enhanced  15  25  35  45

1 Underwritten by Blue Shield of California Life & Health Insurance Company.

2 All Premier PPO plans (except Premier PPO 20), Enhanced PPO,

 Premier PPO 20  Enhanced PPO 30

 Enhanced PPO 40

1,2

Base PPO, Shield Spectrum PPO, Simple Savings and Smile In Network

 Simple Savings 3400/6800

 Access+ HMO Enhanced 40

1,2,3

Only dental plans are pending regulatory approval.

3 Simple Savings plans are HSA-eligible high-deductible health plans.

 Access Baja HMO 10  Other _______________

Section 2 – Employee Information –

(please type or print clearly, use black ink) Bolded items denote required ﬁelds.

Social Security number

Employer (group) name

Do not write in shaded area

Group number

Last name

First name

Effective date requested:

____ /____ /_______

Full time hire date:

Language Preference:  English  Spanish  Chinese  Vietnamese

 Other ________________

Employment Status:  Full time employee, actively working at least 30 hours per week for this employer

 Part time employee working at least 20 hours per week for this employer

Job title/classiﬁcation

Home address (street, city, state, ZIP)

Mailing address (if different than home address)

Work phone number:

Home phone number:

How would you prefer we contact you?

 E-mail  Standard mail

Telephone  Work  Home – Blue Shield

Email address

will use your preferred method when possible.

Date of birth:

Gender:  Male  Female

Marital Status:  Single  Married  Domestic partner

Do you have eligible dependents?  Yes  No How many?_________ How many are enrolling?____________

Are any additional sheet(s) attached to this application? How many sheets?_________

Are any eligible dependents not enrolling on this plan covered by any form of health insurance?  Yes  No

If you, your spouse, or your dependent(s) are refusing coverage, please complete and sign the Refusal of Coverage form at the end of this application.

HMO provider information: Blue Shield of California directory website:

HMO Personal Physician name

Provider number

IPA/MG number

Existing patient?

 Yes  No

Dental HMO Provider name

Dental Provider number (Do not use ofﬁce number)

Existing patient?

 Yes  No

Please be sure to return all pages of this form as the last page contains your signature which is necessary to process these changes.

Missing information may delay processing. Fax requests to (209) 367-6475.