This page gives you immediate access to the plan description and forms
you will need to help employers and their staff get the information
that is easy to understand and use.
Blue Cross - Forms & Applications
< Go Back    or view forms & apps for:
Aetna  |  American Fidelity  |  Blue Cross  |  Blue Shield  |  First Dental Health  |  Health Net  |  Kaiser  |  PacifiCare  |  Sharp  |  Sterling HSA  |  The Standard  |  UHC  |  Unum
 
If more than one result is on this page, hit 'Alt + s' (just hold the Alt button and hit the s key) on your keyboard to find the next matching result
Select a Category...    Group Medical   |   Dental   |   Life & Disability   |   Vision
Company
Group Medical - EMPLOYEE
 Description Form # Rev Date Fillable
Blue Cross
Employee Application

 EmployeeElect for 2-50 Member Small Groups. 3345 1-09  
Blue Cross Employee Application - Spanish Spanish Version IS2295 05-04  
Blue Cross Employee Application - Chinese Chinese Version IS2296 05-04  
Blue Cross Employee Application - Korean Korean Version 5547 05-04  
Blue Cross Affidavit Domestic Partnership Affidavit for Domestic Partnership Form. IS2327 03-05  
Blue Cross Benefits Employee Application BeneFits from Blue Cross. Small business solutions. A package that fits. 10526 2-08  
Blue Cross Benefits Employee Application - Spanish Spanish Version 10526_SP 2-08  
Blue Cross Benefits Employee Application - Chinese Chinese Version 10526_CH 2-08  
Blue Cross Benefits Employee Application- Korean Korean Version 10526_KO 2-08  
Blue Cross Custodial Parent Verification Form Custodial Verification Form. Custodial Parent or Person having custody of child N/A N/A  
Blue Cross Employee Addition Application 2-50 Exisiting Small Group Employee Addition Application. For Adding New Employees and Their Eligible Dependents to Existing Coverage. 8480 2-08  
Blue Cross Employee Addition Application - Spanish 2-50 Exisiting Small Group Employee Addition Application. For Adding New Employees and Their Eligible Dependents to Existing Coverage. 8480SP 2-08  
Blue Cross Change of Coverage   IS2418 8-08  
Blue Cross Affidavit Domestic Partnership   MCAFR1146CEN 2-08  
Blue Cross Affidavit Domestic Partnership - Spanish   MCAFR1146CSP 2-08  
Blue Cross Affidavit Domestic Partnership - Chinese   MCAFR1146CCH 2-08  
Blue Cross Affidavit Domestic Partnership - Korean   MCAFR1146CKO 2-08  
Company
Group Medical - EMPLOYER
 Description Form # Rev Date Fillable
Blue Cross Employer Application EmployeeElect for 2-50 Member Small Groups. 5773 6-08
Yes
Blue Cross Benefits SG Employer Application BeneFits from Blue Cross Form. Small business solutions. A package that fits. 10525 2-08  
Blue Cross Employers Statement of Understanding Employer’s Statement of Understanding Application Attachment when selecting:
• Any HSA-Compatible plan(s)
• Any plan in the Group BeneFits portfolio		 10722 03-07  
Blue Cross HSA Group Initiation Form Employer Group HSA Initiation Form. PNA-113 03-07  
Blue Cross Information Change Form USE THIS FORM FOR:
• Notification of terminations of employees/dependents
• COBRA/Cal-COBRA notifications
– COBRA is for groups of 20 or more
– Cal-COBRA applies to groups with 2 to 19 full- and part-time employees.
• Leave of Absence notification and/or Address changes		 ECASH1219CEN 12-07  
Blue Cross POP Application Premium Only Plan Enrollment Form. SC1380 02-05  
Blue Cross POP Employer Guide Brochure and Application Employer’s Guide to the Premium Only Plan (P.O.P.) and Application. 3949 04-05  
Blue Cross POP Quote Engine (Excel File)   SC1226 08-04  
Blue Cross Complete the following to receive quotes for groups of 2-50 eligible employees within 2 business days. BCAFR3549C 7-08  
Blue Cross All HMO Medical plans, Premier $10/$20 Copay plans and PPO $30/$40 Copay plans are offered by BCC. All other Medical,Term Life and AD&D products are offered by BCL&H. IS2417 04-05  
Blue Cross Sole Proprietor, Partner, Corporate Officer Statement   ME8054 04-05  
Company
Group Medical - OTHER
Description Form # Rev Date Fillable
Blue Cross Absolute Assignment Form   MCAFR2657B 3-08  
Blue Cross Benefits How To Request Changes   ECASH1792CEN 2-08  
Blue Cross Benefit Modification Inquiry This form may be used for preliminary review of existing groups (with medical coverage already) requesting to upgrade to the EmployeeElect Plus program. This form is not to be used for Risk Adjustment Factor (RAF) reviews,benefit downgrades or adding medical coverage to existing dental/life groups. IS2419 4-05  
Blue Cross Ceridian FSA COBRA Applicaiton Ceridian Application for Services for Blue Cross of California Small Group Clients. N/A 12-02  
Blue Cross Change Beneficiary or Name Form   MCAFR2653B 2-08  
Blue Cross Change Of Coverage Application Small Group Change of Coverage Application (For Existing Enrollments Only). IS2418 5-04  
Blue Cross Change Request for EE and EC   ECASH1218CEN 2-08  
Blue Cross Conditions of Enrollment Seasonal Coverage Conditions of Enrollment for Employer Groups Offering Seasonal Coverage. 10080 9-04  
Blue Cross Conditions of Enrollment for Start-up Companies Conditions of Enrollment for Start-Up Companies. IS2416 4-06  
Blue Cross Custodial Parent Verification   MCAFR1147CEN 2-08  
Blue Cross Employers Statement of Understanding   ECASH1810CEN 2-08  
Blue Cross Enrollment App Phone Addendum   BCASH3515C 7-08  
Blue Cross Evidence of Insurability   MCAFR2701B 2-08  
Blue Cross Group Participation HSA Enrollment Package This HSA Enrollment Package (the “Enrollment Package”) is for the Chase HSA that is provided by JPMorgan Chase Bank, N.A. (“Chase”). By completing and signing the attached Enrollment Form and Adoption Agreement, you are selecting Chase as your Health Savings Account (“HSA”) custodian and are agreeing to the terms and conditions associated with the account and are requesting Chase to open an HSA on your behalf. As the custodian of your HSA, Chase will manage your account and safeguard your HSA funds. PNA-214 1-09  
Blue Cross HIPAA Applicants Form Authorization for Use of Protected Health Information. 8857 4-03  
Blue Cross HIPAA Members Form Agents (and other 3rd parties) are the primary users of this form. When you call Blue Cross on behalf of your client about a claim or to discuss their protected health information, the member must sign this form to authorize Blue Cross to release their information to you. 8858 4-03  
Blue Cross HSA Agreement Form HSA Agreement Form ECALT2715C 4-08  
Blue Cross HSA Group Initiation Form   PNA-113 3-07  
Blue Cross HSA Group Participant Enrollment Package This HSA Enrollment Package (the “Enrollment Package”) is for the Chase HSA that is provided by JPMorgan Chase Bank, N.A. (“Chase”). By completing and signing the attached Enrollment Form and Adoption Agreement, you are selecting Chase as your Health Savings Account (“HSA”) custodian and are agreeing to the terms and conditions associated with the account and are requesting Chase to open an HSA on your behalf. As the custodian of your HSA, Chase will manage your account and safeguard your HSA funds. PNA-114 10-08  
Blue Cross Patient Claim Form Claim form MCAFR1148CEN 2-08  
Blue Cross Spanish - HIPAA Authorization Form In Spanish SC8517 4-03  
Blue Cross Spanish - HIPAA Authorization Form In Spanish SC8570 4-03  
Blue Cross Translator Statement Exceptions to Standard Enrollment/Translator’s Statement. 7077 6-03  
Blue Cross Underwriting Guidelines For Businesses with 2-50 Employees. IW8007 11-05  
Select a Category...    Group Medical   |   Dental   |   Life & Disability   |   Vision
Company
Dental
 Description Form # Rev Date Fillable
Blue Cross Employee Application Small Group Voluntary Dental Coverage Small Group Employee Application for Voluntary Dental Coverage 5990A 05-04  
Blue Cross Group Dental Coverage Employee Application IS2346 05-02  
Blue Cross Change Request Form - 51-99 Dental Plan 51-99 Dental Plan Change Request Form ECAFR2482CEN 2-08  
Blue Cross Change Request Form - BeneFits Dental Plan BeneFits Dental Plan Change Request Form MCAFR2387CEN 2-08  
Blue Cross Change Request Form - Dental Blue Dental Blue® Plan Change Request Form MCAFR0684CEN 2-08  
Blue Cross Change Request Form - Dental Plan Dental Plan Change Request Form MCAFR2374CEN 2-08  
Blue Cross SmileNet Application SmileNetSM Dental Discount Program for Small Groups 2-50 11038 10-05  
Select a Category...    Group Medical   |   Dental   |   Life & Disability   |   Vision
Company
Life Insurance
Description Form # Rev Date Fillable
Blue Cross Life Enrollment for Existing Employees and/or Beneficiary Designation Form WL404 05-06  
Blue Cross Change Request Form - Life Plan Small Group Life Enrollment for Existing Employees and/or Beneficiary Designation Form MCAFR1149CEN 2-08  
Blue Cross This simple worksheet can give you an approximate idea of how much supplemental life insurance you need. 7324 10-04  
Company
Vision
 Description Form # Rev Date Fillable
Blue Cross        
< Go Back    or view forms & apps for:
Aetna  |  American Fidelity  |  Blue Cross  |  Blue Shield  |  First Dental Health  |  Health Net  |  Kaiser  |  PacifiCare  |  Sharp  |  Sterling HSA  |  The Standard  |  UHC  |  Unum