Get Nc Bcbs F110 2016-2025

The NC BCBS F110 form is essential for enrolling or making changes to your dental coverage with Blue Cross and Blue Shield of North Carolina. This guide will provide you with clear and detailed instructions on how to complete the form online, ensuring a smooth process.

Follow the steps to successfully complete the NC BCBS F110 form online.

1. Click ‘Get Form’ button to access the NC BCBS F110 form and open it in your preferred editor.
2. Begin with Section A, Employee Information. Fill in your social security number, date of birth, last name, first name, mailing address, date employed, sex, marital status, city, state, zip code, employee ID number, work phone number, home phone number, and email address.
3. If you are making a change, proceed to Section B. Check all applicable boxes for the changes you want to make, such as name changes, adding or removing dependents, and the reasons for these changes.
4. Section C must be completed by an employer, including details like the employer's name, group number, effective date, and details regarding qualifying events for COBRA coverage.
5. In Section D, Coverage Selection, indicate the options you desire for coverage including the type of plan and benefit period maximum amount.
6. If applicable, complete Section E regarding prior dental coverage by attaching any necessary documentation.
7. In Section F, Family Information, list all individuals who will be enrolling or dropping coverage, including their names, social security numbers, birthdates, and sex. Mark whether each person is being added or deleted.
8. Finalize your application in Section G by signing and dating the Employee Authorization, confirming that all information provided is accurate.
9. Once all sections are completed, you can save your changes, download a copy for your records, print the form, or share it as necessary.

Complete your NC BCBS F110 application online today for a seamless enrollment experience.