Blue Cross And Blue Shield - Account Application Form For Insured Business (Page 2 of 3) in pdf

Blue Cross And Blue Shield - Account Application Form For Insured Business Page 2

Part 2

Account Information

Eligible employees are defined as: permanent full-time employees regularly working 30 or more hours per week and permanent

part-time employees working at least 20 hours, but less than 30 hours per week, at the employer’s usual place of business and paid

in accordance with state and federal wage requirements.

A. What is the total number of your employees? (Includes full and part-time individual(s) who received payments from the employer

that are subject to FICA taxes.) This information is very important to classify your company correctly for Federal Medicare Secondary

Payer (MSP) requirements.

B. What is the total number of your permanent employees that are actively working and eligible for health care coverage?

C. Of the employees described in B, what is the total number that you have not enrolled because they are enrolled in another group

health plan through their spouses or through other insurance such as Mass Health or Connector plans?

(Documentation of other coverage, for each employee, must accompany this application)

Medical

Dental

D. Of the employees described in B, what is the total number you are enrolling in all your health care coverages?

Medical

Dental

E. Of the employees identified in B, what is the total number that have not selected health care coverage?

(Do not include those identified in C.)

Medical

Dental

F. What is the total number of other personnel that are not actively working but are eligible for your group health care

coverage? (For example: Retirees, COBRA)

Medical

Dental

Please indicate the number enrolled in the following categories based on total enrollment in all health insurance plans.

Full-Time Employees

Part-Time Employees

Retireees Under 65

Retireees Over 65

COBRA

Working Aged

What is the probationary time period (or waiting period) for employees enrolled after the original effective date of this group?

Are domestic partners eligible for coverage?

qYes

qNo

If yes, please check one:

qSame sex only

qSame and opposite sex

Blue Cross And Blue Shield - Account Application Form For Insured Business Page 2