HTML Preview Blank Employee Application Sample page number 1.
EMPLOYEE APPLICATION
EFFECTIVE DATE OF COVERAGE:
BCBSAZ ID NUMBER
(existing member)
EMPLOYEE NUMBER (employer use only)
MEDICAL PLAN TYPE
PPO
PPO HSA QUALIFIED
_____________
HMO
OTHER
BLUEALLIANCE*
OPTION
DENTAL
_____________
DENTAL
OPTION
MEDICAL COVERAGE
EMPLOYEE ONLY
EMPLOYEE & SPOUSE
EMPLOYEE & CHILDREN
FAMILY
DENTAL COVERAGE
EMPLOYEE ONLY
EMPLOYEE & SPOUSE
EMPLOYEE & CHILDREN
FAMILY
*MOST IN-NETWORK ARIZONA PROVIDERS FOR THIS LOCAL NETWORK PLAN ARE LOCATED ONLY IN MARICOPA COUNTY.
ARE YOU DECLINING COVERAGE
FOR:
SELF?
Y N
SPOUSE?
Y N
DEPENDENT(S)?
Y N
If yes, include the appropriate reason
code(s) in Section II below. (A list of
reason codes is found near the bottom
of page 2.)
NEW GROUP
OPEN
ENROLLMENT
OPT FOR A FLEXIBLE SPENDING ACCOUNT (FSA) AVAILABLE FROM HEALTH EQUITY
I want a healthcare FSA
I want a dependent care FSA
I do not want an FSA
HealthEquity is an independent company, contracted with BCBSAZ to administer FSAs for group benefit plans.
SECTION I – INFORMATION REGARDING YOUR EMPLOYER
EMPLOYER NAME
LOCATION
GROUP NUMBER
JOB CLASSIFICATION
I
II
OTHER (SEE EMPLOYER)
SECTION II – INFORMATION REGARDING THE EMPLOYEE
MARK ONE:
ADD
CHANGE
WAIVER
CODE
(SEE
BACK)
_____
SOCIAL SECURITY NUMBER
Required. See (O) on page 2.
LAST NAME
FIRST NAME
M.I.
PHYSICAL ADDRESS (NUMBER, STREET & APARTMENT NO.)
CITY
STATE
ZIP + FOUR
MAILING ADDRESS
CITY
STATE
ZIP + FOUR
DATE OF BIRTH (MM/DD/YYYY)
MALE
FEMALE
MARRIED SINGLE
DATE OF MARRIAGE (MM/DD/YYYY)
WORK TELEPHONE (AREA CODE AND NO.)
HOME TELEPHONE (AREA CODE AND NO.)
EMAIL ADDRESS
See page 2 (N) regarding
e-mail authorization
OTHER COVERAGE
INFORMATION:
Will you or your dependents be covered by other health insurance in addition to BCBSAZ?
If yes, please complete the other coverage information below.
YES NO
OTHER HEALTH PLAN COVERAGE NAME
CARRIER PHONE NO. (AREA CODE & NO.)
POLICY HOLDER LAST NAME
ID/SOCIAL SECURITY NUMBER
GROUP/POLICY NO.
EFFECTIVE DATE (MM/DD/YYYY) MEDICARE CARD NO. PART A EFFECTIVE DATE PART B EFFECTIVE DATE
Complete the following for all dependents. If you have more than 3 dependents, complete a separate form.
New employees: Complete the following information for each eligible dependent including those declining or waiving coverage.
Enrolled employees: to add or remove dependent(s) or change coverage options, only include the persons affected by the change.
1
MARK ONE:
ADD
DELETE
CHANGE
WAIVER
CODE
(SEE
BACK)
_____
LAST NAME FIRST NAME
M.I.
SOCIAL SECURITY NUMBER
Required. See (O) on page 2
DATE OF BIRTH (MM/DD/YYYY)
MALE
FEMALE
RELATIONSHIP
OTHER HEALTH PLAN COVERAGE NAME
CARRIER PHONE NO. (AREA CODE & NO.)
POLICY HOLDER LAST NAME
IDENTIFICATION NUMBER
GROUP/POLICY NO.
EFFECTIVE DATE (MM/DD/YYYY)
MEDICARE CARD NO.
PART A EFFECTIVE DATE PART B EFFECTIVE DATE
2
MARK ONE:
ADD
DELETE
CHANGE
WAIVER
CODE
(SEE
BACK)
_____
LAST NAME FIRST NAME
M.I.
SOCIAL SECURITY NUMBER
Required. See (O) on page 2
DATE OF BIRTH (MM/DD/YYYY)
MALE
FEMALE
RELATIONSHIP
OTHER HEALTH PLAN COVERAGE NAME
CARRIER PHONE NO. (AREA CODE & NO.)
POLICY HOLDER LAST NAME
IDENTIFICATION NUMBER
GROUP/POLICY NO.
EFFECTIVE DATE (MM/DD/YYYY)
MEDICARE CARD NO.
PART A EFFECTIVE DATE PART B EFFECTIVE DATE
3
MARK ONE:
ADD
DELETE
CHANGE
WAIVER
CODE
(SEE
BACK)
_____
LAST NAME FIRST NAME
M.I.
SOCIAL SECURITY NUMBER
Required. See (O) on page 2
DATE OF BIRTH (MM/DD/YYYY)
MALE
FEMALE
RELATIONSHIP
OTHER HEALTH PLAN COVERAGE NAME
CARRIER PHONE NO. (AREA CODE & NO.)
POLICY HOLDER LAST NAME
IDENTIFICATION NUMBER
GROUP/POLICY NO.
EFFECTIVE DATE (MM/DD/YYYY)
MEDICARE CARD NO.
PART A EFFECTIVE DATE 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.
X
EMPLOYEE’S SIGNATURE DATE
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