Blank Employee Application Sample

EMPLOYEE APPLICATION EFFECTIVE DATE OF COVERAGE: MEDICAL PLAN TYPE PPO PPO HSA QUALIFIED HMO OTHER BLUEALLIANCE BCBSAZ ID NUMBER (existing member) DENTAL DENTAL EMPLOYEE NUMBER (employer use only) _____________ OPTION _____________ OPTION MEDICAL COVERAGE EMPLOYEE ONLY EMPLOYEE SPOUSE EMPLOYEE CHILDREN FAMILY DENTAL COVERAGE EMPLOYEE ONLY EMPLOYEE SPOUSE EMPLOYEE CHILDREN FAMILY ARE YOU DECLINING COVERAGE FOR: SELF Y N SPOUSE Y N DEPENDENT(S) Y N NEW GROUP OPEN ENROLLMENT If yes, include the appropriate reason code(s) in Section II below.. POLICY HOLDER LAST NAME PART A EFFECTIVE DATE IDENTIFICATION NUMBER PART B EFFECTIVE DATE I certify to all of the following on behalf of myself and the persons listed on this application as eligible dependents: (1) I have read this entire form (2) I understand and agree to its terms (3) I apply for enrollment and/or waive group benefits as indicated on this form, subject to all terms and conditions of the coverage, as offered by my employer (4) the information I have provided is accurate and complete, and I understand that provision of false information may result in fines and criminal penalties and (5) if any part of any premium for coverage or other financial services will be paid through payroll deduction, I authorize my employer to periodically deduct from my wages, and remit amounts necessary to continue the coverage and any services..