BCBS - PHCS Enrollment Application

Applicant Details:

Which policy would you like to apply for?

These plans are listed on Step 1 of the previous page.

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Format: (000) 000-0000.

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.

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.

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.

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

Name on Card

Card Number

Card Type

Expiration Date

CVC Number from the back of the card

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.

BCBS - PHCS Enrollment Application

Health Disclosure Questions

Payment Information

Bank Information