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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
Group ACH Authorization
2/13/2019 Group Forms