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BCL&H are Independent licensees of the Blue Cross Association (BCA). The Blue Cross name and symbol are registered service marks of the BCA. Applicant s Social Security or ID No. ALL INFORMATION YOU PROVIDE MUST BE ACCURATE. 1. Applicant Information (Please print) Applicant s Last Name Reason for Application (Check one) o New enrollment(s) First Name o Change of Coverage M.I. To change existing Blue Cross plan, please enter ID No: Home Address (Must be complete: P.O. Box not accepta.
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