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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) |
| 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. |
| 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 |