Bc-iu 20 36 5/00

Individual Enrollment Application
Blue Cross Dental SelectHMO and all medical plans except the Basic PPO 1000, PPO Saver, BC Life Share 1000 and BCLife Share 500, are offered by Blue Cross of California. The Basic PPO 1000, PPO Saver, BC Life Share 1000, BC Life Share500, PPO Dental and Term Life products are offered by BC Life & Health Insurance Company.
1. Application must be completed by the applicant in blue or black ink.
Applicant’s Social Security No.
2. Any family member currently pregnant (whether or not listed on the application)
or in the process of adoption is not eligible.
1. Applicant Information (Please print)
Reason for Application (Check one)
Primary Applicant’s Last Name
First Name
To change existing Blue Cross plan, please enter I.D. No: Home Address (Must be complete: P.O. Box not acceptable) For Summary Bill (existing), please enter I.D. No: Primary Applicant’s Social Security No.
County Applicant Resides in (Required) Mailing Address (If different than above) or P.O. Box If possible, do you want e-mail notification? Maiden Name of Applicant / Spouse Has any person listed on this application resided outside the U.S. for the past three (3) consecutive months? 2. Choice of Blue Cross Individual Coverage
Do you wish to choose FamilyElect for medical coverage?
If yes, proceed to Section 3 on the following page. Refer to the 4-digit codes in parentheses below to indicate medical coverage choices in Section 3B for each
family member. (NOTE: If choosing FamilyElectSM, all family members will be assigned the same original effective date.)
If no, select ONE medical plan choice below.
If you are choosing Dental coverage or Term Life Insurance, please complete the appropriate sections below.
MEDICAL COVERAGE
PlanScape®
Low Option:
Coverage
Medium Option: Ⅺ PPO Share 1500 (7889)
Alternative
High Option:
* If you have chosen Blue Cross Individual HMO or Blue Cross HMO Saver
Ⅺ Individual HMO* (Areas 4, 5, 6 only) (7898) medical coverage, please complete Section 3A on the following page.
Coverage
If you do not qualify for an HMO plan, would you like to be enrolled in PlanScape® coverage with a 50% or more increase in premium?
Ⅺ No, DO NOT enroll me
Ⅺ Yes – Specify any PlanScape coverage you wish to be enrolled in:
To determine eligibility for HIPAA guaranteed enrollment, please go to Section 5, questions E-E3.
Enrollment
If eligible, please enroll me in:
LIFE INSURANCE COVERAGE
DENTAL COVERAGE
Please list applicants you wish to provide Dental coverage for:
Ⅺ BC Life & Health Term Life Insurance
NAME OF APPLICANT
DATE OF BIRTH
Ⅺ Blue Cross Dental Saver SelectHMO* (ZE6N) Ⅺ Blue Cross Dental Premier SelectHMO* (ZE8N) Complete Section 4 on page 2.
* For any of the Blue Cross Dental SelectHMO coverages,
DO NOT SUBMIT PREMIUM
please indicate the Provider number below:
FOR LIFE INSURANCE.
FOR BLUE CROSS USE ONLY – DO NOT WRITE BELOW
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Applicant’s Social Security No.
3. Applicants for Coverage
Please list ALL applicants (youngest to oldest) applying for coverage.
3A. For HMO Use Only
3B. FamilyElect
Choose a physician for each family
Medical Coverage
If a family member’s last name is different than yours, please explain.
ACCURATE
member from the Provider Directory.
Choose Medical
Primary Care
Current Plan code number(s)
Relation
Last Name
First Name
Social Security No.
Date of Birth Age
Height Weight
Physician (PCP)
from Section 2
20 Ⅺ Female
30 Ⅺ Husband Spouse
40 Ⅺ Wife
3C. Dependent Information: Do you claim all children listed above who are between the ages of 19 through 22 as dependents on your Federal Income Tax?
If “NO”, any child between the ages of 19 through 22 who is not claimed on your Federal Income Tax is NOT eligible as a dependent but may apply individually.
4. BC Life & Health Term Life Insurance
Applicants and/or any dependents that are approved for Level I and Level I+20 coverage will also qualify for BC Life & Health Insurance Term Coverage
at an additional charge. Applicants under the age of one year are not eligible for life insurance. DO NOT SUBMIT PREMIUM FOR LIFE INSURANCE.
✓ Amount of Coverage
Beneficiary Address
Name of Family Member
Name of Beneficiary
Relationship
$30,000 $50,000*
City / State / ZIP Code
* NOTE: The $50,000 amount is not available to applicants under the age of 19. If selected by an approved applicant under age 19, the selection will default to $30,000.
If beneficiary is not listed and policy is issued, death benefits will be paid in accordance with the Beneficiary Provision on page 3 of the Policy.
I have discussed Life Insurance with my agent and decline – Initial: __________
5. Prior Insurance History and HIPAA Eligibility – Please answer ALL of the following questions.
Blue Cross of California Companies credit prior coverage toward the preexisting period for those applicants who apply for coverage within 63 days after termination
of qualifying prior coverage as prescribed by law. To obtain credit toward the preexisting period, please complete the following.
A. Has any applicant been a member of Blue Cross of California or any other health insurance plan within the last 5 years? . Ⅺ Yes
B. Has any applicant had coverage in the last 63 days? . Ⅺ Yes
If you answered “Yes” to A or B above, please provide the following information.
Name of applicant(s): ____________________________________________ Certificate/Policyholder No: _________________________________
Plan name: __________________________________ State: _____________ Most recent coverage start date: ___________
I certify that my coverage terminated/will terminate on (date): _____________________________________________________________________ C. Has any applicant ever been eligible for or received benefits from Medicaid, Medi-Cal, Medicare, California State Disability
Insurance, Workers’ Compensation, or an employer-sponsored health plan? . Ⅺ Yes If yes, start date (Mo/Day/Yr): ___________________________________ End date (Mo/Day/Yr): _____________________________________________
D. Have any applicants identified above been declined, postponed, had a waiver applied, or charged an extra premium for life,
disability or health insurance or had such insurance rescinded? . Ⅺ Yes HIPAA Coverage – If I do not qualify for the Individual Plans, I would like to be considered for coverage under HIPAA. I understand
that no underwriting is required and rates may be significantly higher than for the Individual Plans. If I qualify, please offer the HIPAA
coverage and send complete details regarding my options and rates . Ⅺ Yes
If yes, name of applicant(s) applying for HIPAA coverage: _________________________________________________________________________
If yes, please answer the following questions.
1) Are you currently covered by or eligible for Medicaid, Medicare or any other employer-sponsored health insurance benefits,
or do you have other health coverage? . Ⅺ Yes If yes, you are not eligible for HIPAA coverage.
2) Have you had a minimum of 18 months of continuous health coverage most recently under an employer-sponsored group health plan, that ended within the last 63 days for a reason other than fraud or non-payment of premium? . Ⅺ Yes If yes, you will be asked to provide the Certificate of Coverage from your former employer or carrier OR a letter from the employer giving us the
Start date (Mo/Day/Yr): ______________ End date (Mo/Day/Yr): ____________ Name of applicant: ________________________________________
Name of insurance carrier(s): ____________________________________ Phone no. (________) ______________________________________
If no, you are not eligible for HIPAA coverage.
3) Were you eligible for COBRA or Cal-COBRA? . Ⅺ Yes If yes, start date (Mo/Day/Yr): ______________________________________ End date (Mo/Day/Yr): _______________________________________
If no, please explain: ____________________________________________________________________________________________________
If COBRA or Cal-COBRA is not exhausted, you are not eligible for HIPAA coverage.
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Applicant’s Social Security No.
6. Health History Include information on ALL family members you wish to enroll.
6A. Health History Questionnaire – ALL QUESTIONS MUST BE ANSWERED OR THE APPLICATION WILL BE RETURNED.
Give COMPLETE details of any “Yes” answers in Section 6C on the following page.
Has any person listed on this application, in the last 10 years, had any signs or symptoms, seen a health care provider, had treatment recommended including
prescription medications, received treatment, or been hospitalized for any of the following conditions as stated in questions 1 through 14?
1. Brain/Nervous – frequent and/or severe headaches, migraines, seizures,
8. Musculoskeletal – bone, joint and/or muscle pain, injury or
epilepsy, dizziness, weakness, fainting, numbness/tingling, head injury, disorder of joint/tendon/ligament/disc, weakness of back/spine/ paralysis, stroke, confusion, memory loss, loss of consciousness, sleep joint, amputation, physical handicap, polio, arthritis, gout, apnea, narcolepsy, used a sleep monitoring device, etc.
sprain/strain, prosthesis, joint replacement, hardware, internalfixations (i.e., pins, plates, screws), fractures, TMJ, etc.
2. Heart/Circulatory – chest pain, angina, high or low blood pressure,
heart disease, heart attack, heart murmur, palpitations, valve 9. Endocrine/Metabolic –
replacement, pacemaker, defibrillator; or blood clot, phlebitis, varicose a) Diabetes, thyroid, anemia, adrenal disorders, pituitary disorders, veins, enlarged lymph nodes, blood/bleeding disorder, anemia, rheumatic lupus, AIDS/ARC, immune disorders, scleroderma, Epstein-Barr/ 3. Lungs/Respiratory – allergies, infections, sinusitis, asthma, bronchitis,
b) Is any applicant a candidate for, or a recipient of an organ or emphysema, pneumonia, tuberculosis, difficulty breathing, shortness of breath, chronic cough, spitting/coughing up blood, etc.
c) Is any applicant on the waiting list to donate an organ or bone 4. Digestive – tonsillitis, infections of the mouth/throat, jaw/chewing
problems, gastric reflux, ulcers, hernia, colitis, intestinal problems, 10. Has any applicant ever had cancer, tumor/growth, leukemia, cyst?
diarrhea, rectal problems/bleeding, polyps, hemorrhoids, gallbladder, pancreatitis, liver disease, cirrhosis, hepatitis, jaundice, unexplainedweight loss, etc.
11. Skin Disorder/Problems – cancer, melanoma, pre-cancerous
lesion, psoriasis, keratosis, warts, birthmarks, 2nd or 3rd degree burns, 5. Urinary – kidney, bladder, urinary tract infections, stones,
acne, fungal infections, eczema, dermatitis, herpes, scars/keloids, or urinary incontinence, blood in urine, etc.
revisions of cosmetic or reconstructive surgery, infections, etc.
6. Male Reproductive System –
12. Eyes, Ears, Nose and Throat – diseases or problems of the eyes or sight,
a) Prostate, infertility, low sperm count, impotence, sexual dysfunction, ears or hearing, nose or breathing, throat or swallowing – such as: any penile or scrotal implant, sexually transmitted disease, herpes, genital infections, crossed eyes, glaucoma, cataracts, detached retina, polyps, deviated nasal septum, excessive snoring, problems with tonsils oradenoids, sleep apnea, etc.? b) Is any male listed on this application expecting a child or in the process of adoption or surrogate pregnancy with anyone, whether 13. Nervous, Mental, Emotional, Behavioral – eating disorder,
anorexia/bulimia, depression, anxiety, alcohol or substance abuse/ dependency, counseling, member of a support group, bi-polar, 7. Female Reproductive –
chemical imbalance, attention deficit disorder, schizophrenia, a) Breast disorder/cyst, lump, breast implants, fibroid tumors, obsessive-compulsive or panic disorder, etc.
endometriosis, pelvic pain, menstruation disorders, abnormal/absent 14. Congenital Abnormalities, Birth Defects – cleft lip/palate, club foot,
menstrual bleeding, uterine fibroids, ovarian cysts, infertility, webbed fingers or toes, mental retardation, developmental delay, Down’s miscarriages, sexually transmitted disease, herpes, genital warts, etc.
syndrome, heart/lung problems, skull/facial deformities, birthmark, etc.
b) Does any proposed female member menstruate? 15. Has any applicant taken any prescribed medications in the last
12 months? If yes, complete 6E on page 4.
If yes, indicate if: Ⅺ Applicant/spouse Ⅺ Dependent(s) Dependent name(s): _______________________________________________ 16. Has any applicant consulted a provider for any condition or symptom(s) Yes No
in the last 12 months, for which a diagnosis has not been established?
c) Has it been more than 40 days since her/their last menstrual period? 17. Has any applicant been advised to see a dentist or oral surgeon
If yes, explain: _____________________________________ in the last 12 months?
d) Has any female applicant had a pelvic exam/Pap smear? 18. Has any applicant been a patient in a hospital, clinic, surgicenter,
sanatorium, or other medical facility as an inpatient or outpatient (excluding childbirth) in the last 10 years? If yes, complete 6C on page 4. e) Date and result of last pelvic exam/Pap smear for each female over age 16.
19. Has any applicant ever had an abnormal physical exam, laboratory
Name: ______________________ Mo/Day/Yr: ____________ Ⅺ Normal
results, x-rays, EKG, MRI, CT scan or been advised to undergo further Name: ______________________ Mo/Day/Yr: ____________ Ⅺ Normal
Name: ______________________ Mo/Day/Yr: ____________ Ⅺ Normal
20. Has any applicant ever seen, received treatment from or consulted any Yes No
doctor, or any other person providing health care services for any other Ⅺ Ⅺ f) Is any female applicant pregnant, or in the process of adoption or condition or symptom(s) not listed on this application? IMPORTANT: Applicant’s medical conditions, which occur after the signature date and before the original effective date, are considered in the final underwriting decision.
6B. Other Health Questions
1. During the past 12 months, has any applicant smoked cigarettes,
3. Has any applicant consumed any alcoholic beverages
cigars, or pipes, or used chewing tobacco? (Amount: A drink is 12 oz. of beer, 6 oz. of wine, or 1 oz. of liquor.) Name: ______________________________ Date discontinued: _____________________
Name: __________________________________ Type: __________________
Name: ______________________________ Date discontinued: _____________________
Name: __________________________________ Type: __________________________
2. Has any applicant used marijuana, cocaine, heroin,
methamphetamines, LSD, or any other illegal or controlled drugs, or substances in the last 10 years, or been diagnosed as chemically 4. Has any applicant been advised to reduce alcohol intake
Name: _______________________ Substance: __________ Date discontinued: ________
Name: __________________________________ Date discontinued: _______________
Name: _______________________ Substance: __________ Date discontinued: ________
Name: __________________________________ Date discontinued: _______________
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Applicant’s Social Security No.
6C. Professional Services
Give COMPLETE details below of any “Yes” answers to the questions in Section 6A.
Question # Name of Family Member (As identified on Physician’s Record)
Name of Hospital, Clinic and/or Person Providing Care Treatment Rendered (i.e., X-ray, lab, surgical procedure, etc.) / Results
Question # Name of Family Member (As identified on Physician’s Record)
Name of Hospital, Clinic and/or Person Providing Care Treatment Rendered (i.e., X-ray, lab, surgical procedure, etc.) / Results
Question # Name of Family Member (As identified on Physician’s Record)
Name of Hospital, Clinic and/or Person Providing Care Treatment Rendered (i.e., X-ray, lab, surgical procedure, etc.) / Results
6D. Last Doctor Visit (for any reason including check-up) – Provide information for ALL family members you wish to cover.
Name, Phone No. & Fax No.
Family Member
Reason for Visit
of Physician or Hospital
Abnormal (Explain)
Complete Address / City / State / ZIP Code
Name: ____________________________________
Phone: _________________ Fax: ______________
Address: __________________________________
Name: ____________________________________
Phone: _________________ Fax: ______________
Address: __________________________________
6E. Prescription Medications – List all medications taken within the last 12 months by any family member listed on this application.
Medication / Dosage / Frequency
Illness for
Name and Phone No.
Family Member
Prescribed
Discontinued
which Medication
of Physician or Hospital
(i.e., Lopressor/100mg/daily)
is Prescribed
Name: ____________________________________
Phone: ____________________________________
Name: ____________________________________
Phone: ____________________________________
Name: ____________________________________
Phone: ____________________________________
To provide further information, please use additional sheets if necessary. List the page number, section name, and question number
No. of sheets
you are explaining. Also, please identify the applicable family member. All additional sheets must be signed by the applicant.
attached
STATEMENT OF ACCOUNTABILITY – To be completed when the applicant cannot complete the application.
I, _______________________________ , personally read and completed this Individual Enrollment Application for the applicant named below because: I translated the contents of this form and to the best of my knowledge obtained and listed all the requested personal and medical history disclosed by: I also translated and fully explained the “Application Conditions and Agreement.” Signature of Translator (Required) 4
7. Application Conditions and Agreement
Applicant’s Social Security No.
IMPORTANT: It is important that you carefully read and fully understand the following.
All Applicants age 18 and over must personally read, agree to and sign the following. If an Applicant does not read English, the translator must sign and submit a
Statement of Accountability for translating this entire application (see page 4).
PPO Plan Applicants only
I, the undersigned, understand that under the Blue Cross plan in which I am enrolling, I will be entitled to lesser benefits if I use an out-of-network hospital or physician than if I use a networkhospital or physician.
Effective Date (PPO Applicants only) REQUESTING AN EFFECTIVE DATE DOES NOT GUARANTEE UNDERWRITING TO BE COMPLETED BEFORE THE DATE REQUESTED.
Ⅺ I request that Blue Cross assign my effective date if my application is approved. My effective date will be assigned as either the 1st or the 15th of the month following the approval date of my application. Please note: If you are adding a dependent or changing coverage, your effective date will always be the first of the month following approval.
Ⅺ If Blue Cross approves my application, please assign an effective date of the Ⅺ 1st or Ⅺ 15th of ____________________.
This date must be after the signature date but not greater than 75 days from the signature date on this application.
HMO Applicants only
I understand I will only receive benefits for services by, or authorized by, the HMO facility I selected on this application.
Ⅺ If Blue Cross approves my application, please assign an effective date of the Ⅺ 1st or Ⅺ 15th of the month following approval.
High Deductible EPO for MSA Applicants only
I understand that the High Deductible Plans are designed for Exclusive Provider Organization (EPO) usage, and that using non-participating providers could result in significantly higher out-of-pocket costs. I understand that having this coverage does not establish an MSA. To do so, I must contact a qualified financial institution. Also, I understand that I should contact my tax advisor.
Eligible/Ineligible Applicants
Blue Cross will enroll all eligible family members unless otherwise instructed.
Ⅺ I, the Applicant, request that Blue Cross not enroll any eligible applicants unless ALL family members qualify.
Authorization
Authorization to Obtain or Release Medical Information: I authorize any physician or other health care professional, hospital or other health care facility, counselor, therapist, or any
other medical or medically related facility or professional to give Blue Cross of California, its affiliates (“Blue Cross”), their respective agents, employees, designees, or representatives, including
my Blue Cross agent, or broker, any and all information or records relating to medical history, medical examinations, services rendered, or treatment given, including treatment for alcohol
abuse, substance abuse, mental or emotional disorders, A.I.D.S. (Acquired Immune Deficiency Syndrome), or A.R.C. (AIDS-related Complex), of me or any of my dependents applying for or
having Blue Cross coverage. I understand that this information may be collected in connection with the review, investigation or evaluation of an enrollment form or of any claim for benefits.
HIV TESTING PROHIBITED: California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance.
I also authorize Blue Cross to disclose all such medical or personal information related to myself or any covered dependent, to a health care provider, a health care service plan, a self-insurer,or any insurance company for the purpose of investigating or evaluating any claim for benefits. This authorization is effective immediately and shall remain in effect for a period of thirty (30)months, except that it shall remain effective for use in connection with any claim for benefits for as long as any Blue Cross coverage may be in effect. A photocopy of this authorization is as validas the original, and I and my Blue Cross agent or broker, am entitled to receive a copy of this form.
Signatures (Required) – IMPORTANT: All applicants over age 18 must sign and date.
If you currently have health coverage, we strongly recommend that you maintain your current coverage and request an effective date of 60 to 75 days
from the date of application. This will help ensure that your application is processed before you surrender your present insurance.
Agreement (all applicants)
By applying for coverage, I, the undersigned, agree to the following:
1. Blue Cross may decline my application. No coverage comes into effect until Blue Cross approves this application and informs me in writing. The effective date of my coverage, if this application is
accepted, will be assigned by Blue Cross at its discretion.
2. Even if I pay money with this application, that money is only a deposit against future premiums if this application is accepted. Cashing my check does not mean my application is approved. If this application is declined, neither Blue Cross nor any affiliated company shall have any liability to me or anyone else listed on it, except for the obligation to return the money submitted with thisapplication. If this application is not accepted, neither I nor anyone listed on it will be entitled to benefits or coverage from Blue Cross.
3. The selling agent has no authority to promise me coverage or to modify Blue Cross underwriting policy or the terms of any Blue Cross coverage.
4. Any of my dependents listed on this application who are over the age of 18 years have read this application and have provided complete and accurate information for this application. Also, I have done everything necessary to be able to assure you that all information about any children under the age of 18 listed on this application is true and complete. I understand and agree that I aloneam responsible for the accuracy and completeness of this application. I understand and agree that no one listed on this application will be eligible for coverage if any information is false orincomplete and that Blue Cross may revoke coverage if it discovers that any information on this application is incomplete or false.
5. If the applicant is a minor, I accept full legal and financial responsibility for the coverage and information provided on this application. (Court documents establishing guardianship must be submitted if the responsible adult is not the parent.) 6. In no event shall Blue Cross or any affiliated company have any liability to the applicant if the application is not approved, except for the obligation to return the money submitted with this application if this application is not approved, and neither shall any coverage exist nor shall the applicant be entitled to any benefits unless and until this application is approved by the MedicalUnderwriting Department of Blue Cross of California.
7. I understand Blue Cross of California may use any information prior to the effective date of coverage in considering my application, including medical conditions which occur after the signature and before the original effective date.
I have personally read and completed this application. If I am accepted, this application will become part of the contract between Blue Cross and me. I and any enrolled family members agree to
abide by the terms of that contract.
Arbitration: I agree that any dispute between me or any enrolled family member, and Blue Cross of California and/or its affiliates must be resolved by binding arbitration if the amount in dispute exceeds
the jurisdictional limits of the Small Claims Court. Any such dispute will be resolved not by lawsuit or resort to court process, except as California law provides for judicial review or arbitration
proceedings. Under this coverage, both I and my enrolled family, and Blue Cross of California and its affiliates, are giving up the right to have any dispute decided in a court of law before a jury. Blue Cross
and the Member also agree to give up any right to pursue on a class basis any claim or controversy against the other.
Signatures (Required) – IMPORTANT: All applicants over age 18 must sign and date.
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Applicant’s Social Security No.
ATTACH BLANK, VOIDED CHECK
PLEASE ATTACH
FOR BANK DRAFT AUTHORIZATION,
PREMIUM CHECK HERE.
IF APPLICABLE, HERE.
DO NOT TAPE.
DO NOT TAPE.
8. Payment Method Premium payment required.
8A. Initial Premium Payment by Credit Card
8B. Payment Type
New members only. Not available to make a coverage change.
Ⅺ Monthly Billing (Available with Monthly Checking Account Deduction
Initial premium is for Medical and Dental fees only.
Authorization only.)
1. Submit the one (1)-month premium and a voided check.
2. Complete the Monthly Checking Account Deduction Authorization.
Credit card: (VISA or MasterCard only) 3. If your application is approved, the premium for all products selected, including dental and/or life, will be deducted from your checking account Ⅺ Optional Bimonthly – Submit the two (2)-month premium.
Ⅺ Optional Quarterly – Submit the three (3)-month premium.
Signature of cardholder: x
Please note: First payment will be credited to approved applicants only.
8C. Monthly Checking Account Deduction Authorization
Complete this section and attach a blank check marked “VOID” to this form (DEPOSIT SLIPS NOT ACCEPTABLE). Attach a check for one (1) month’s
premium above where indicated. If the account listed below is a joint account, both account holders’ signatures are required.
AUTHORIZATION – As a convenience to me, I request and authorize you to pay and charge to my account checks drawn on that account by and payable to the order of BLUE
CROSS OF CALIFORNIA provided there are sufficient collected funds in said account to pay the same upon presentation. I agree that your rights in respect to each such debit shall
be the same as if it were a check drawn on you and signed personally by me. I authorize Blue Cross of California to initiate debits (and/or corrections to previous debits) from my
account with the financial institution indicated for payment of my Blue Cross of California dues. This authority is to remain in effect until revoked by me in writing, and until you
actually receive such notice, I agree that you shall be fully protected in honoring any such debit. I further agree that if any such debit be dishonored, whether with or without cause
and whether intentionally or inadvertently, you shall be under no liability whatsoever even though such dishonor results in forfeiture of insurance.
NOTE: Should your withdrawal not be honored by your bank, you will automatically be removed from Monthly Checking Account Deduction and be billed quarterly. After 12
months, you may re-apply for the monthly checking account deduction option. You may incur a $25 service charge for any withdrawal not honored.
Authorized Signature (As it appears in the financial institution’s records) Authorized Signature (As it appears in the financial institution’s records) To Be Completed By Your Blue Cross-Appointed Agent
1. Are you aware of any information not disclosed on this application relating to the health, habits or reputation of any person listed on this application which might have a bearing on the risk? . Ⅺ Yes 2. Did you see the proposed subscriber (and spouse, if applying) at the time this application was executed? . Ⅺ Yes If no, please explain: ________________________________________________________________________________________ 4. Was the Term Life Insurance option selected? (If yes, first Term Life Insurance payment will be billed.) . Ⅺ Yes 5. Was the Monthly Checking Account Deduction Authorization form completed? (Only if applicable) . Ⅺ Yes Suite No. / Personal Mail Box (PMB) No.
661 836-3000 661 836-3003 amer@aminsuranceonline.com PLEASE NOTE: If neither box is checked, the Service Agreement will be mailed directly to the primary applicant.
Mailing address:
Agent: Please mail this application to the following address: Blue Cross of California • P.O. Box 9041 • Oxnard, CA 93031-9041
Blue Cross of California and BC Life & Health Insurance Company are Independent Licensees of the Blue Cross Association (BCA). Blue Cross andthe Blue Cross symbol are Registered Marks of the BCA. PlanScape is a Registered Mark and FamilyElect is a Service Mark of WellPoint Health Networks Inc.
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