Blue Cross And Blue Shield - Account Application Form For Insured Business
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1
2
3Account Application Form for Insured Business
Introduction
Thank you for choosing one of our health and/or dental benefit programs.
To ensure that your application is processed without delay, please complete the information requested in Parts 1, 2 and 3 (if applicable).
Read and sign Part 4 where indicated.
Part I
Introduction
1. Employer’s Legal Name
Doing Business As (DBA)
Employer’s Business Address (Street, City, Zip Code)
Executive Contact
Title
Telephone
Fax
Email Address
Billing Address (Street, City, Zip Code)
qSame as Business Address
Billing Contact
Title
Telephone
Fax
Email Address
qCorporation
qPartnership
qProprietorship
qOther (Explain Below)
Nature of Business
Employer’s Tax ID No.
Human Resources Administrator’s Name
Telephone
Fax
Email Address
2. Information about any subsidiaries or affiliates that are a separate legal entity and whose employees are to be included.
Give subsidiary’s or affiliate’s legal name and business address (Street, City, State, Zip Code)
Telephone
qOther (Explain Below)
qCorporation
qPartnership
qProprietorship
Nature of Business
Employer’s Tax ID No.
3. Date Company was Established (Month./Year)
q
q
4. Does Employment vary seasonally?
Yes
No
If yes, please explain below
Explanation:
5. Please List the name(s) of prior carrier(s)
MEDICAL
DENTAL
1.
1.
2
2
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Parent category: Business