Forms and Documents

Need a form to help a client enroll in one of our health plans? Or do you have clients already enrolled in our plans who need claim or other forms? 

Enrollment forms

Use these forms to help your group or individual clients apply for coverage. These forms are also included on the individual plan pages in our Products and Services section. 

Small groups

General

• Enrollment Checklist
• Small Group Enrollment Tool*
• Group Rework Agent Checklist
• Membership Application
• Tobacco Usage Form
• Agent Compliance Attestation Form
• Benefit Request Form
• Coverage Cancellation Request

Blue Dental^SM

• Blue Dental Application

Business BlueEssentials^SM

• Business BlueEssentials Master Application and Group Request for Coverage

BlueMeasure^SM - Level Funded Plans

• BlueMeasure Enrollment Checklist
• BlueMeasure Census* 
• BlueMeasure Health Statement
• BlueMeasure Benefit Selection
• BlueMeasure Membership Application
• BlueMeasure EFT Form

Business Blue Basic Rx Plans

• Business Blue Basic Rx Enrollment Checklist
• Benefit Selection Form

Chamber Blue

• Chamber Blue Master Application and Group Request for Coverage
• Membership Application

Legacy Groups

• Group Request for Coverage (non-Chamber groups)

Medicare Supplement

• BlueCare^® Application
• Blue Select^® Application
• Plus Endorsement Application

ICHRA

• AccrueHealth Enrollment Census
• AccrueHealth New Group Checklist
• Administrative Services Terms and Conditions
• Plan of Benefits
• ICHRA Administrative Services Agreement
• ICHRA Electric Funds Transfer Authorization Form
• ICHRA Employee Enrollment Form
• Payroll Express Program Brochure

Group Solutions

• Group Solutions Administrative Services Agreement

Companion Life

We offer life insurance through Companion Life. Companion Life is a separate company responsible for all services related to life insurance. 

• Companion Life Employer Participation Application
• Companion Life Group Application
• Companion Life RFP

Member forms

Do your clients need forms to manage their benefits? Our Members section includes a full library of forms, including claims, prescription drugs, HIPAA authorization and more. 

*All items marked with an asterisk will download as an external file