Please Complete Steps 1-7 Step 1) Tell us about yourself Step 2) Tell us about your household Step 3) Choose a plan and payment Step 4) Tell us if you have other dental and/or vision insurance Step 5) Review notification and authorization information Step 6) Review payment and billing information Step 7) Sign the Application If this Application is being completed by an agent/producer, please complete and return the Producer Attestation with the rest of the completed Application. Note: You'll need to print the remittance slip in this application and mail it with your first premium payment. Online Enrollment Form Tell us about yourself I have an existing Blue Cross/Blue Plus® member ID number: I am a new applicant: Applying for coverage for myself only Applying for coverage for myself and my dependents I am currently enrolled in a Blue Cross Dental or Vision individual plan: Adding a dependent Making a plan change Please note: Processing of your Application may be delayed if this form is not completed in its entirety. When you include Social Security numbers (SSNs), we can process your Application more efficiently, but you are not required to include them for your dependents or yourself. Male Female Permanent Home Address (No PO Box #) Correspondence Address (If different from home address) Billing Address (If different from permanent home and correspondence address) I have been a permanent resident of Minnesota for a minimum of 183 days Important: We can only offer coverage to permanent Minnesota residents. Yes No Will you or any other enrollee receive any premium or cost-sharing payments made by a specific person or entity, directly or indirectly, by any ineligible third party? Yes No Please Complete Steps 1-7 Step 1) Tell us about yourself Step 2) Tell us about your household Step 3) Choose a plan and payment Step 4) Tell us if you have other dental and/or vision insurance Step 5) Review notification and authorization information Step 6) Review payment and billing information Step 7) Sign the Application If this Application is being completed by an agent/producer, please complete and return the Producer Attestation with the rest of the completed Application. Note: You'll need to print the remittance slip in this application and mail it with your first premium payment. Online Enrollment Form Who will be on the Plan? Tell us about everyone who is applying for coverage. Dependent 1 Male Female Does this person live at the same address as you? Yes No If No, list address: Add a dependent Dependent 2 Male Female Does this person live at the same address as you? Yes No If No, list address: Add a dependent Dependent 3 Male Female Does this person live at the same address as you? Yes No If No, list address: Add a dependent Dependent 4 Male Female Does this person live at the same address as you? Yes No If No, list address: Add a dependent Dependent 5 Male Female Does this person live at the same address as you? Yes No If No, list address: Add a dependent Dependent 6 Male Female Does this person live at the same address as you? Yes No If No, list address: Add a dependent Dependent 7 Male Female Does this person live at the same address as you? Yes No If No, list address: Please Complete Steps 1-7 Step 1) Tell us about yourself Step 2) Tell us about your household Step 3) Choose a plan and payment Step 4) Tell us if you have other dental and/or vision insurance Step 5) Review notification and authorization information Step 6) Review payment and billing information Step 7) Sign the Application If this Application is being completed by an agent/producer, please complete and return the Producer Attestation with the rest of the completed Application. Note: You'll need to print the remittance slip in this application and mail it with your first premium payment. Online Enrollment Form Coverage and payment selection Your coverage will begin on the first day of the month following receipt of your completed Application unless you indicate a different requested effective date below – whichever is later. Requested effective dates must be within 90 days following receipt of your completed Application. Dental Coverage Option Freedom $1,500 Freedom $2,000 Value Standard Value Enhanced Value Premium Preferred Bill Frequency Options: Monthly Quarterly Semiannual Annual Premium Payment ($): My coverage will be for: Contractholder only Contractholder and one dependent Family Requested Effective Date: If adding a child dependent outside of renewal, check the reason for the add: Newborn Newborn grandchild Adoption/placement for adoption Court ordered Vision Coverage Option Value Standard - with Exam Value - Eyewear Only Plan Annual Premium Payment (Annual Billing Only) ($): My Coverage will be for: Contractholder only Contractholder and one dependent Family Requested Effective Date: If adding a child dependent outside of renewal, check the reason for the add: Newborn Newborn grandchild Adoption/placement for adoption Court ordered Please Complete Steps 1-7 Step 1) Tell us about yourself Step 2) Tell us about your household Step 3) Choose a plan and payment Step 4) Tell us if you have other dental and/or vision insurance Step 5) Review notification and authorization information Step 6) Review payment and billing information Step 7) Sign the Application If this Application is being completed by an agent/producer, please complete and return the Producer Attestation with the rest of the completed Application. Note: You'll need to print the remittance slip in this application and mail it with your first premium payment. Online Enrollment Form Dental and/or Vision insurance information If you have a current Blue Cross Individual/Family dental and/or vision policy, your current policy will be replaced as of the effective date of your new plan. If your current coverage is through an employer or another insurance carrier, Blue Cross cannot cancel that coverage for you. Have you or any family members applying for a dental plan under this Application had continuous comparable coverage immediately prior to the effective date of the dental plan selected? Yes No If you answered Yes, please provide the supporting documents listed below and and fill out the following information. NOTE: Previous dental coverage will be reviewed and may impact your eligibility or benefits. Supporting document(s) must be provided to prove eligibility. Discount dental coverage does not qualify as comparable coverage. Supporting Documentation: Letter for previous dental carrier showing comparable coverage Must be on the official carrier letterhead Must list all persons covered under the plan and their coverage dates Summary of plan benefits Please Complete Steps 1-7 Step 1) Tell us about yourself Step 2) Tell us about your household Step 3) Choose a plan and payment Step 4) Tell us if you have other dental and/or vision insurance Step 5) Review notification and authorization information Step 6) Review payment and billing information Step 7) Sign the Application If this Application is being completed by an agent/producer, please complete and return the Producer Attestation with the rest of the completed Application. Note: You'll need to print the remittance slip in this application and mail it with your first premium payment. Online Enrollment Form Notification and authorization information By completing this enrollment Application, I understand that I will be submitting an actual request for enrollment and I agree to the following: My signature on this Application indicates that I have read and fully understand the following statements when applying for dental/vision coverage through Blue Cross and Blue Shield of Minnesota (Blue Cross). I understand and agree that coverage, if approved, will begin as specified on page 4. I authorize Blue Cross either to use information from my check to make a one-time electronic funds transfer from my account or to process the payment as a check transaction. When Blue Cross uses information from my check to make an electronic funds transfer, funds may be withdrawn from my account as soon as the same day Blue Cross receives my check and I will not receive my check back from my financial institution. I understand that coverage will be provided under an individual contract. I understand that Blue Cross does not issue individual coverage through an employer. Blue Cross is not responsible for any action taken by an employer that results in this coverage being considered group coverage under state or federal law. The employer is solely responsible for any such finding. For purposes of obtaining information in connection with this Application, reinstatement, or change in coverage benefits, this release is valid as long as I am continually covered with Blue Cross. I am entitled to receive a copy of any release I sign. Blue Cross primarily relies upon the information provided and full disclosure of the information listed on this Application in the decision whether to accept the applicant and/or dependent(s) listed on this Application for coverage. I acknowledge the importance of providing accurate and complete information. I acknowledge I must answer all questions in the Application, even if I and/or dependent(s) listed on this Application currently have coverage or had prior coverage with Blue Cross. I understand I must be a permanent resident of Minnesota to be eligible for this coverage and I hereby attest that as of the effective date of my contract I am a permanent resident of Minnesota and am eligible for this coverage. I also understand that if this attestation is determined not to be true, Blue Cross will rescind my contract and coverage, and no claims will be paid. I further attest that I was not encouraged or advised to apply for this coverage in connection with any offer by an ineligible third party (described on page 1) to directly or indirectly pay all or some of my premiums or cost sharing. I agree to notify Blue Cross immediately of any change in my or my dependents enrollment information between the date of this Application and the effective date of coverage. Failure to notify Blue Cross of any change in the information contained on this Application may result in the denial of claims, rescission of the contract, the issuance of a contract amendment, or a premium adjustment. By providing an email address, I agree to receive communications and marketing materials related to the plan I selected and products offered by or made available from Blue Cross and its affiliates. I may unsubscribe or change my email address at any time by following the instructions included in each email communication. By providing a telephone number, I expressly consent to accept and receive communications and marketing materials related to the plan I selected and products offered by or made available from Blue Cross and its affiliates, via text message or voice call to my mobile device and to the cellular/mobile telephone number(s) that I provided. NOTE: Email and text messaging transmission cannot be guaranteed to be secure or error-free as information could be intercepted, corrupted, lost, destroyed, arrive late or incomplete, or contain viruses. As the recipient of an email or text message from an unsecured email or device, Blue Plus does not accept liability for any errors or omissions in the contents of the email or text message, which arise as a result of email or text message transmission. Upon request, I agree to furnish additional information needed concerning eligibility of any dependent(s) enrolling for coverage. I have read the preceding instructions, statements and answers and represent them to be true and complete to the best of my knowledge and belief. I understand that my or my dependents enrollment eligibility and coverage of benefits under this dental or vision coverage may be subject to a lock-out period. Dental coverage may also be subject to a waiting period. I understand and agree Blue Cross will act in reliance upon the information I have provided on this Application, which materially affects enrollment eligibility and may result in the denial of claims, rescission of the contract, the issuance of a contract amendment, or a premium adjustment. I understand and agree that payment of a claim does not preclude the right of Blue Cross to deny future claims or take any action it determines appropriate, including rescission of the contract and seeking repayment of claims already paid. I understand that this Agreement renews on an annual basis. I acknowledge that if my first payment is not made with this Application, the first premium payment is due by the due date printed on my first invoice. I understand that failing to pay before this due date will result in my Application being voided. I understand that payments in advance of the amount will be credited to my future payments. I understand my payment must be received and processed in full before claims can be paid for any eligible services received. I acknowledge that if my ongoing premium payments are not received within the plan grace period, my plan will be terminated. Please Complete Steps 1-7 Step 1) Tell us about yourself Step 2) Tell us about your household Step 3) Choose a plan and payment Step 4) Tell us if you have other dental and/or vision insurance Step 5) Review notification and authorization information Step 6) Review payment and billing information Step 7) Sign the Application If this Application is being completed by an agent/producer, please complete and return the Producer Attestation with the rest of the completed Application. Note: You'll need to print the remittance slip in this application and mail it with your first premium payment. Online Enrollment Form Payment and billing information For dental coverage, you can pay your dental plan premium monthly in advance to Blue Cross. If it is convenient, you may pay more than your monthly amount. We will apply excess amounts on a monthly basis during the calendar year. These amounts will be subject to premium increases on the date the increase is effective. For vision coverage, you must pay your vision plan premium annually. We must receive and process your full premium payment before we can pay claims for any eligible services you receive. If your premium payment is not received within the plan grace period, your plan will be terminated. The termination date will be the last month in which we received your required payment. Claims for eligible services will not be processed unless your current premium has been paid in full. Please Complete Steps 1-7 Step 1) Tell us about yourself Step 2) Tell us about your household Step 3) Choose a plan and payment Step 4) Tell us if you have other dental and/or vision insurance Step 5) Review notification and authorization information Step 6) Review payment and billing information Step 7) Sign the Application If this Application is being completed by an agent/producer, please complete and return the Producer Attestation with the rest of the completed Application. Note: You'll need to print the remittance slip in this application and mail it with your first premium payment. Online Enrollment Form Sign Application If this Application is completed as an electronic or online application, both parties agree to conduct this transaction electronically. Please Complete Steps 1-7 Step 1) Tell us about yourself Step 2) Tell us about your household Step 3) Choose a plan and payment Step 4) Tell us if you have other dental and/or vision insurance Step 5) Review notification and authorization information Step 6) Review payment and billing information Step 7) Sign the Application If this Application is being completed by an agent/producer, please complete and return the Producer Attestation with the rest of the completed Application. Note: You'll need to print the remittance slip in this application and mail it with your first premium payment. Online Enrollment Form For Producer Use Only Producer Attestation Attention Producer: If you have questions about completing this Application, please call the Producer Line at 1-888-878-0138. If this section is not fully completed, you will not be assigned as the AOR. A Producer must complete this section to act on the Applicant's behalf. I attest I have reviewed the completed Application with the Applicant(s) and: I certify that I have met the requirements listed in Minnesota Statute 60K.46 subdivision 4 regarding suitability, as well as those requirements set forth in the Agent Code of Conduct and within the Blue Cross and Blue Shield of Minnesota and Blue Plus contract. Note: Visit Agent Central and search for "Agent Code of Conduct". I am not aware, based on the Applicant's responses to my inquiries, of any factors impacting the eligibility of the Applicant and each of his/ or her dependents applying for coverage I further understand that no producer may accept risk or pass on any eligibility requirements, make or alter the terms of the Application or policy, or waive any contractual rights or requirements. I attest the Applicant was present and signed this Application in my presence. I provided a copy of the submitted Application to the Applicant(s), in its entirety, immediately in a secure manner pursuant to all applicable laws I agree to retain a copy of the submitted Application for my records and to provide a copy of the submitted Application to Blue Plus upon request.
