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Member Enrollment Application Tips

Tips for completing the Large Group Member Application 100+ 
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.
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
Please complete COBRA Notification Form listing people participating in COBRA.
Current COBRA participants must complete enrollment form if using COBRA Solutions.
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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.