BCBS - PHCS Enrollment Application
Applicant Details:
Which policy would you like to apply for?
Please Select
Blue Cross Blue Shield 1500 Classic
Blue Cross Blue Shield 2500 Classic
Blue Cross Blue Shield 5000 Classic
Blue Cross Blue Shield 7350 Value
Blue Cross Blue Shield HSA 5000
PHCS Limited 1M PPO - 250 Deductible
PHCS Limited 1M PPO - 500 Deductible
PHCS Limited 1M PPO - 750 Deductible
PHCS Gold 2500 RBP
PHCS Bronze 5000 RBP
PHCS Copper 7350 RBP
PHCS HSA 5000 RBP
These plans are listed on Step 1 of the previous page.
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Social Security #
*
Date of Birth
*
Spouse Name
Spouse Date of Birth
Please list all Dependents and DOB to be covered by the policy.
Health Disclosure Questions
Has the prospective client or any of his/her dependents been under the care of a doctor currently or in the past 5 years for any of the following conditions: cancer, heart disease (including Bypass), Heart Attack, Heart Surgery, or Stroke? *Dependent child(ren) covered through the end of the month they turn 26. Domestic partners are NOT covered. ONLY legal spouses to be covered. Please answer question for you and all your dependents to be covered.
*
Yes
No
Has the prospective client or any of his/her dependents applying for coverage in the past 5 years been home-bound or incapacitated or incapable of self-support due to a medical condition? *Dependent child(ren) covered through the end of the month they turn 26. Domestic partners are NOT covered. ONLY legal spouses to be covered.Please answer question for you and all your dependents to be covered.
*
Yes
No
Has the prospective client or any of his/her dependents applying for covered, been under the care of a doctor currently or in the past 5 years for Autoimmune or blood disease i.e., Lupus MS, Anemia, AIDS, HIV, Hemophilia, IBS, Crohn's? *Dependent child(ren) covered through the end of the month they turn 26. Domestic partners are NOT covered. ONLY legal spouses to be covered.Please answer question for you and all your dependents to be covered.
*
Yes
No
Has the prospective client or any of his/her dependents, been under the care of a doctor currently or in the past 5 years for Organ Failure or Organ Transplant for Kidney, Liver, Lung, Heart and or any form of organ support i.e., dialysis? *Dependent child(ren) covered through the end of the month they turn 26. Domestic partners are NOT covered. ONLY legal spouses to be covered.Please answer question for you and all your dependents to be covered.
*
Yes
No
Has the prospective client or any of his/her dependents applying for coverage currently pregnant or expecting? *Dependent child(ren) covered through the end of the month they turn 26. Domestic partners are NOT covered. ONLY legal spouses to be covered.Please answer question for you and all your dependents to be covered.
*
Yes
No
Has the prospective client or any of his/her dependents applying for coverage, currently being treated for condition(s) you have been hospitalized for in the past 5 years? *Dependent child(ren) covered through the end of the month they turn 26. Domestic partners are NOT covered. ONLY legal spouses to be covered.Please answer question for you and all your dependents to be covered.
*
Yes
No
Has the prospective client or any of his/her dependents applying for coverage, been under the care of a doctor currently or in the past 5 years for respiratory disorders, Emphysema, Chronic Bronchitis, COPD or Chronic Pneumonia? *Dependent child(ren) covered through the end of the month they turn 26. Domestic partners are NOT covered. ONLY legal spouses to be covered.Please answer question for you and all your dependents to be covered.
*
Yes
No
Has the prospective client or any of his/her dependents seeking coverage, been under the care of a doctor currently or in the past 5 years for musculoskeletal disorders i.e. Back Disorders, Muscular Dystrophy, Cerebral Palsy, Dermatomyositis, Compartment Syndrome, Sciatica or Osteoporosis? *Dependent child(ren) covered through the end of the month they turn 26. Domestic partners are NOT covered. ONLY legal spouses to be covered.Please answer question for you and all your dependents to be covered
*
Yes
No
Has the prospective client or any of his/her dependents seeking coverage been under the care of a doctor currently or in the past 5 years for substance abuse or substance dependency? *Dependent child(ren) covered through the end of the month they turn 26. Domestic partners are NOT covered. ONLY legal spouses to be covered. Please answer question for you and all your dependents to be covered.
*
Yes
No
Has the prospective client or any of his/her dependents seeking coverage been under the care of a doctor currently or in the past 5 years as a Type 1 Diabetic? *Dependent child(ren) covered through the end of the month they turn 26. Domestic partners are NOT covered. ONLY legal spouses to be covered.Please answer question for you and all your dependents to be covered.
*
Yes
No
Has the prospective client or any of his/her dependents seeking coverage, been under the care of a doctor currently or in the past 5 years for a previous major surgery? Or have an upcoming planned surgery? *Dependent child(ren) covered through the end of the month they turn 26. Domestic partners are NOT covered. ONLY legal spouses to be covered.Please answer question for you and all your dependents to be covered.
*
Yes
No
By typing my name below, I understand that all information above is true and correct. I understand that information listed above will be used to enroll myself and/or dependents in a health insurance policy. I understand that by typing my name below, I am signing this application electronically. I agree that my electronic signature is the legal equivalent of my manual signature on this application.
*
Payment Information
Visa or Mastercard - eCheck also available - PLEASE ONLY USE ONE OPTION BELOW
Name on Card
Card Number
Card Type
Please Select
Visa
Mastercard
Expiration Date
CVC Number from the back of the card
Bank Information
Name of Financial Institution
Bank Routing Number (9 Digits)
Banking Account Number
Do you have any questions or comments that you would like a broker to answer for you?
I understand that I will be receiving a text message or email for an additional signature when an Enrollment Specialist/Insurance Broker completes the official enrollment.
*
Yes
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