Get Member Enrollment Application

Filling out the Member Enrollment Application online is a straightforward process that enables you to enroll in various health plans offered by Blue Cross and Blue Shield. This guide will walk you through each section to ensure that you complete the application accurately and efficiently.

Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to access the application and open it in your browser.
2. Begin by filling out Section 1, which requests personal information. Provide your date of hire, effective date, employment status, and the reason for your application. Include your full name and contact information.
3. In Section 2, indicate the type of coverage you want by selecting from the available medical and specialty plans. If you decline coverage, ensure you mark the appropriate option and sign the form.
4. Move to Section 3 to disclose any other insurance coverage you or your dependents may have. Specify the policy holder's name, insurance company, and additional details as required.
5. Fill out Section 4 by providing information about your family members who are applying for coverage along with selection of a Primary Care Physician if required.
6. Section 5 focuses on life insurance. Complete this section only if you are applying for life coverage. Provide your job title, salary, and indicate your chosen coverage options.
7. Complete Sections 6 and 7, which contain health-related questions. Answer all questions truthfully regarding past medical history for each covered individual.
8. In Section 8, provide additional details if you answered 'Yes' to any questions in the previous sections about serious illnesses or treatments.
9. Review all information for accuracy before moving to the certification section. Acknowledge the rights and obligations, and sign and date the application.
10. Finally, save changes to your application. You can download, print, or share the completed form as needed.

Start your Member Enrollment Application online today to easily secure your health coverage.