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Health & Wellness
A total-health solution that surrounds everyone with the help they need to live healthier, feel better and save money doing it.
Member Enrollment Application Tips
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|
| Current COBRA participants must complete enrollment form if using COBRA Solutions.|