Farm Bureau Marketing Materials Order Form
  1. Indicate the materials you want to order by completing the “quantity” field. You can search by form name or number by using Ctrl + F.
  2. Proceed to the bottom of the form to enter the required information in the fields below.

    If you experience problems with this form, or have questions about your order, please send an e-mail message to
Form NumberForm NameQuantity
70510 x 13 Envelope with Important Plan Information message - must be used when mailing Medicare PPO or Rx materials to prospects and beneficiaries
523310 x 13 Envelope with BlueSenior Classic Medicare Supplement plan info on front - not for mailing of Medicare PPO or Rx materials/kits
1898Postage-Paid Return Envelope - Individual Underwriting Department (9 x 4)
1899Postage-Paid Return Envelope - Individual Underwriting Department (6 x 9)
1901Postage-Paid Return Envelope - Individual Underwriting Department (13 x 10)
Form NumberForm NameQuantity
N-11-183 (English)BlueCard Program (for members to locate providers throughout the U.S.)
N-11-183 (Spanish)BlueCard Program (Spanish version for members to locate providers throughout the U.S.)
N-11-187BlueCard Worldwide Program (for members to locate providers around the world)
42-046Summary of Benefits and Coverage postcard
89832-pocket folder: Health Plans for Individuals Under age 65
8909Generic BCBSNE 2-pocket folder
89752-pocket Medicare Supplement folder
4961One Less Thing to Worry About Flyer
92-096High Deductible Health Plans and HSAs - Group (7-11-14 version for 2015)
9017Conversion Coverage Health Care Plan
42-013Open Look under age 65 individual plan performance brochure
92-140Consumer Guide to the New Health Care Law
92-141Health Care Reform Small Business Guide
36-027Your Guide to Health Care Reform-for brokers and employer-group clients
36-182Health Care Reform: New Benefits, New Costs-for brokers and employer-group clients
36-051 (8-25-14)Benefits for Preventive Services (for grandfathered groups without women's and children's preventive care and screenings benefits, effective 9-1-14)
36-051-3 (8-25-14)Benefits for Preventive Services (for non-grandfathered groups effective on or after 9-1-14)
36-051-3 (12-23-14)Heath Care Reform Benefits for Preventive Services - Non-Grandfathered
92-109-2 (12-4-14)Preventive Health Guidelines (for non-grandfathered plans effective on or after 1-1-15)
92-109 (3-26-14)Preventive Health Guidelines (for grandfathered plans)
36-100Online Tools and Resources from BCBSNE
4975In-Network Providers Card
IMPORTANT NOTE: Beginning June 1, 2011, a $25 broker fee will be charged for every paper application submitted.
Form NumberForm NameQuantity
3087 rev 10-1-14Application for Individual Coverage (use for 2015 ACA-compliant plans)
3179 (3-13-14)Non-Underwritten Change Application (ACA plans)
3179 (9-1-12)Non-Underwritten Change Application (non-ACA plans)
3062TempCare Application and Contract (Use for 2015 applications)
31-095DentalEssentials stand-alone application
3041Medicare Supplement with optional DentalEssentials application
Form NumberForm NameQuantity
36-066NEtwork BLUE Directory
Form NumberForm NameQuantity
Y0052Medicare Scope of Appointment Form
4964Sales and marketing event notification form
5925Cancellation Request
3117HIPAA Form (certification of non-applicability)
8664-4Authorization for Release of Protected Health Information
3205Medicare Supplemental/Medicare Advantage Replacement Notice
3085Non-Tobacco User Certification
1896Preferred Premium Discount Medical Questionnaire
6177Subscriber’s Claim Form (for non-participating providers)
 MedicareBlue Rx Products
Available to Medicare-Certified Agents & Brokers Only
BCBSNE will not send the following MedicareBlue PPO and/or MedicareBlue Rx marketing materials to agents who are not certified to sell Medicare products. Please check the box below to verify you have completed both the AHIP training and the product training to become Medicare certified.

I verify that I am currently certified to sell MedicareBlue products. I understand that selling MedicareBlue products without being certified can result in loss of my sales appointment.
Form NumberForm NameQuantity
RAS 1001R072015 MedicareBlue Rx pre-enrollment kit (includes formulary and sell sheet)
RAS 1001R062014 MedicareBlue Rx pre-enrollment kit (includes formulary and sell sheet)
 Individual DentalEssentials
Form NumberForm NameQuantity
36-141DentalEssentials individual dental brochure
 Individual Benefits Brochures
Form NumberForm NameQuantity
92-133BlueEssentials and SelectBlue benefits brochure (metro area)
92-134BlueEssentials benefits brochure (outside of metro area)
 Product Brochures - Under Age 65 Plans
Form NumberForm NameQuantity
92-069TempCare benefits brochure (use for 2015 plans)
Product Brochures - Over Age 65 plans
Form NumberForm NameQuantity
92-064 rev. 12-1-14BlueSenior Classic Medicare Supplement customer brochure.
36-013Plan L promotional flyer
CMS Pub. 02110Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare (CMS publication for use with Med Supp sales)
RAS1005R062014 How Medicare Works booklet
Rate Books
Form NumberForm NameQuantity
36-1912015 Individual monthly plan ratebook for health care reform-compliant products
Outlines of Coverage
Form NumberForm NameQuantity
9162 rev. 2-1-15BlueSenior Classic Medicare Supplement Plans.
Form NumberForm NameQuantity
4962 PRINTGroup Administration Manual (for groups under our New Claims and Membership System)
4962 CDGroup Administration Manual (for groups under our New Claims and Membership System)
PremierBlue (health plans for employer groups with 100+ eligible employees)
Form NumberForm NameQuantity
92-106PremierBlue Brochure
BlueFreedom (for employer groups of 51-99 employees)
Form NumberForm NameQuantity
8904BlueFreedom Benefits Brochure (for groups effective on and after 8-1-12)
8906BlueFreedom Benefits Options at a Glance (for groups effective on and after 8-1-12)
36-195BlueFreedom plan options brochure (2015 effective dates)
BluePride (for employer groups of 2-50 employees)
Form NumberForm NameQuantity
4727BluePride benefits brochure (for groups effective on and after 1-1-13)
4728BluePride Options at a Glance (for groups effective on and after 1-1-13)
30-009-06BluePride master group application
36-002BluePride individual enrollment form
31-046BluePride employee enrollment form (for 2013 plan year groups)
31-046-01BluePride employee enrollment form (for 2014 plan year groups)
36-186BluePride Plan Options brochure (ACA)
Group Three-Tier Health Plan Options
Form NumberForm NameQuantity
36-147Small Group Three-Tier Options Brochure/Options at a Glance (for groups effective on and after 1/1/13)
36-180SelectBlue Large Group Three-Tier Plan Options – for brokers/group leaders (effective 1/1/14 for employer groups of 100+)
36-185SelectBlue Plus Plan Options brochure (2015 effective dates for groups of 2-50)
Self-Funded Employer Group Health PLan Option
Form NumberForm NameQuantity
92-152Self-Funded Employer Group Health Plan Option Brochure
 SignatureBlue (dental plans for employer groups of 2+)
Form NumberForm NameQuantity
36-029SignatureBlue Dental Brochure
Discount Programs
Form NumberForm NameQuantity
36-050Blue365 discount program flier for all audiences
36-117Individual hearing and vision discount programs flyer
Note: All information is required in order for processing
Please note: We cannot ship to a PO Box.
City, State, Zip:
Phone Number :  
Date: 10/9/2015
If you’re ready to place your order, please click "Submit"