Get Bchp7810317 Membership Application Bc-1019.docx

This guide provides a clear and supportive approach to filling out the BCHP7810317 Membership Application BC-1019 document online. Follow these steps to ensure that your application is completed accurately and submitted successfully.

Follow the steps to fill out the membership application form.

1. Click the ‘Get Form’ button to obtain the application form and open it in your preferred editing tool.
2. Begin by filling out your personal information. Complete your name (last, first, middle initial), address, employee social security number and email address in the designated fields marked as required.
3. Provide your birthdate in the specified format and ensure to include your phone number and cellphone number as required.
4. Indicate your current employer's name and specify your tobacco use status if applicable, selecting 'Yes' or 'No' for the small group only section.
5. Select the reason for your application from the provided options such as 'New Member,' 'Coverage Change,' 'Cancellation,' or 'Reinstatement.' Fill in any additional information required for the selected reason.
6. Choose your medical coverage options by selecting from the available choices such as 'Employee Only,' 'Employee/Child(ren),' 'Employee/Spouse,' or 'Family.' If you have any reasons for not selecting medical coverage, check the applicable options.
7. If applicable, provide your dental coverage preferences in the designated section and specify your life coverage choices, including any dependent life coverage.
8. List all individuals to be covered under your plan, providing their last name, first name, birthdate, gender, social security number, and insurance status.
9. Complete the other coverage information section detailing any additional health, dental, or drug coverage that you or your family members may have.
10. Read and acknowledge the employee certification statement, authorizing the release of information and understanding the terms laid out in the document.
11. Finally, ensure your signature and the date are entered in the appropriate areas. After completing the form, you can save changes, download, print, or share the application as needed.

Complete your BCHP7810317 Membership Application online today for a smooth and efficient process.