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Individual and Family Plan Applications
Medical Plan Application
Explore your plan options, determine your eligibility for financial help, get a price quote, and apply for a Blue Shield individual or family plan.
Dental Plan Application
Current or prospective members should use this application to apply for dental and vision coverage.
Release of Personal Health Information
Authorization for the Use or Disclosure of Health Information
Submit this form to authorize (allow) Blue Shield to release your personal and health information according to your instructions. To protect your privacy, Blue Shield requires authorization to release your information.
Enroll in AutoPay
Log into your Blue Shield account and set up automatic payments for your checking/savings account or credit card.
Beneficiary Change Request
Submit this form to add or delete beneficiaries from a term life insurance plan.
Beneficiary Change Request (PDF, 50KB)
Submit this document when no beneficiary was designated or no designated beneficiary survived the deceased insured.
Beneficiary Affidavit (PDF, 38KB)
Proof of Death Forms
Individual and Family Plans
Beneficiaries should submit this form for proceeds after an insured dies. When submitting the form, include an original certified death certificate.
Group Administrators should submit this form after an employee with Life Insurance dies. When submitting the form, include an original certified death certificate, proof of beneficiary designation, and proof of eligibility.
Proof of Death (PDF, 89KB)
Accelerated Death Benefit Claim
When an insured person becomes terminally ill before age 60, they may get life benefit proceeds prior to death. Before submitting this form, please see plan benefits for specific eligibility.
Accelerated Death Benefit Claim (PDF, 451KB)
Submit this form when the insured is making a dismemberment claim in conjunction with their Accidental Death & Dismemberment coverage.
Dismemberment Claim (PDF, 448KB)
Vision Benefit Claim
Take this form to your appointment to file a claim when getting services from a vision provider that is not in the MESVision provider network.
Vision Benefit Claim (PDF, 73KB)
Life Insurance Forms
Additional Contact Designation
For Individual and Family Plan Subscribers: Complete this form to add an additional contact person(s) to receive a notice of lapse or termination of your life insurance policy if your premium is not paid.