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If you are already a registered Agent or Broker, log on now.
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Need to find a Doctor or Hospital? Check the Online Provider Directory.
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What is BCBSGa's 360° Health® program?
A total-health solution that surrounds everyone with the help they need to live healthier, feel better and save money doing it.
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Member Enrollment Application Tips
PW_A091992
Required blocks to be completed by enrolling Member:
 | Social Security # |
| Company Name |
| Employee Name (last, first, middle initial) |
| Gender |
| Marital Status |
| Birth Date |
| Employee Mailing Address |
| City, State, Zip |
| County |
| Home Phone |
| Business Phone |
| Type(s) of Coverage Applied for (Health, Dental, Vision, Life, STD, LTD. If LTD/STD, need title & income). |
| Date of Employment |
| Effective Date of Coverage |
| Employment Status |
| PCP name/ID # (HMO/POS) (Note: HMO/POS Open Access does not require a PCP selection) |
| Family Members: Name, SS# (if known), Birth Date, All Products applying for, Gender, College age children must have college attending, date first attended, anticipated graduation date. |
| If group is applying for Life products, the Greater Georgia Life Insurance Information section must be completed, including the beneficiary information. For life-only applicants, they may either use the BCBSGa application or they may use the GGL Group Insurance Application. |
Applications must be completed and signed within 60 days of the effective date of coverage.
Required blocks to be completed by employee declining coverage:
| Company Name, Employee Name |
| Indicate all products that employee is refusing coverage for (Medical, Dental, Life, Vision) |
 | | Check Dental or Life only if company is offering the product |
| Insurance Company Name |
| Policyholder Name |
| Employee Signature, Date Signed |
COBRA TIPS
| Current COBRA participants must complete enrollment form if using COBRA Solutions. |
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