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Tips for completing the Small Group Employee Enrollment Form
Required blocks to be completed by enrolling Member:
Social Security #
Company Name
Employee Name (last, first, middle initial)
Marital Status
Birth Date
Employee Mailing Address
City, State, Zip
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.
Health Questions:
All groups with 2-19 employees enrolling in the health insurance MUST answer Section A regardless of whether on a prior carrier
Any questions answered “yes” must be explained in Section B with dates, diagnosis and type of treatment including a list of prescriptions. Any medications being taken must also be listed.

If needed, the Prescription Questionnaire may be used to provide details related to the medication and the medical condition or disorder for which the medication was prescribed.

Any members with the following conditions: Cancer , Diabetes, and/or Cardiac/Hypertension must complete the appropriate questionnaire and attach them to the member application.
All applications must be signed and dated.
Initial Enrollment and Open Enrollment applications/changes must be received within 31 days of the effective date of coverage.
Initial applications/changes received after the effective date of coverage could result in premium rate changes.
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
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Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.