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Forms

Type Title Date Category
Coverage Termination Notice
Whenever an employee/dependent terminates coverage from your group plan, please complete the information requested below and send it to us so that we can provide the employee/dependent with a Certificate of Health Coverage. 		5/10/2019 Group Forms
Employer Risk Appraisal Questionnaire (RAQ)
This form allows BCBSNE to use the information provided in order to evaluate a group's risk characteristics to more accurately establish rates, benefits and eligibility rules as part of the application for coverage. 		2/16/2017 Group Forms
Extension of Coverage for Disabled Dependents
This form allows an extension of coverage request for a mentally or physically handicapped dependent under certain conditions.  		10/27/2014 Group Forms
Extension of Coverage Request for Extended Eligibility to Age 30
10/20/2009 Group Forms
Employer Payment of Medicare Supplement Premiums and Debit Authorization Fillable Form
1/7/2019 Medicare Forms
Employer Payment of Medicare Supplement Premiums and Debit Authorization Form
1/7/2019 Medicare Forms
Farm Bureau Debit Authorization 
8/19/2013 Medicare Forms
Medicare Supplement Replacement Form
3/7/2008 Medicare Forms
Medicare Supplement Debit Authorization
2/13/2019 Medicare Forms
Out of State Notice
1/18/2019 Individual Forms
Coverage Cancellation Request
This form is used for individuals who wish to terminate their coverage with BCBSNE. 		5/18/2018 Individual Forms
Instructions for the Amendment of Application
1/18/2019 Group Forms
Certification of HIPAA Non-Applicability
3/23/2007 Individual Forms
Amendment of Application for Group Contract
8/23/2018 Group Forms
Medicare Supplement Agent of Record Change Request Form
8/6/2018 Medicare Forms
Group Agent of Record Change Request Form
11/7/2018 Group Forms
Request to Cover Biometric Screenings Form
6/17/2020 Group Forms
Armor Health Agent of Record Change Request Form
Please complete the Armor Health Agent of Record Change Request Form to ensure accurate processing of applicant enrollment and the payment of any subsequent producer commissions. 		10/15/2020 Individual Forms
Agency Commission and Bonus Schedule
12/23/2020 Agent of Record
Agency Datasheet
12/23/2020 Agent of Record
Direct Deposit Agreement Form
12/23/2020 Agent of Record
Appointed Agent Form
12/23/2020 Agent of Record
W9
12/23/2020 Agent of Record
Authorized Plan Contacts Form
12/2/2020 Group Forms
Group ACH Authorization (Fillable)
1/20/2021 Group Forms
Group ACH Authorization (Non-Fillable)
1/20/2021 Group Forms
Insurance Producer Agreement
12/23/2020 Agent of Record
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