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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 | |
Group ACH Authorization
|
7/11/2019 | Group 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 | |
Insurance Producer Agreement
|
12/23/2020 | Agent of Record | |
W9
|
12/23/2020 | Agent of Record | |
Authorized Plan Contacts Form
|
12/2/2020 | Group Forms |