We highly recommend that you enroll your clients through our Quote & Apply tool for faster service times and commission payments. If you do need paper application for your clients, we've put all the forms and applications on this page so you can easily download what you need.
Use these applications for your clients who want to enroll in Blue Shield medical plan. They can also apply for dental plan and/or vision coverage.
Get an enrollment application for your clients who want to enroll in Blue Shield dental plan and/or vision coverage.
English (PDF, 2.7MB) Spanish (PDF, 1.3MB)
Chinese (PDF, 1.8MB) Korean (PDF, 1.4MB)
Vietnamese (PDF, 1.2MB)
Individual Term Life Insurance
Make sure your clients are protected by adding individual term life insurance (ITL) to their portfolio of coverage.
New for 2019
• New benefit amounts ranging from $10,000 to $100,000
• Accidental Death and Dismemberment (AD&D) coverage
ITL can be purchased with or without a medical, vision or dental plan, or AD&D coverage. However, AD&D coverage must be purchased with ITL coverage.
Documents needed to apply
ITL and AD&D benefit amounts and premiums sheet (PDF, 62KB)
Credit card authorization form – Binder payment via credit card must be submitted with the application (PDF, 661KB)
Additional ITL forms
Beneficiary Change Form (PDF, 452KB)
Use this form to change a life insurance beneficiary.
Life Insurance Additional Contact Designation Form (PDF, 1.06MB)
Subscriber's Statement of Claim Form (PDF, 418KB)
Subscribers should use this form only when the provider of service does not submit a claim directly to Blue Shield.
International Claim Form (PDF, 327KB)
Download the Blue Shield Global Core International Claim Form.
Dental Claim Form (PDF, 560KB)
Vision Claim Form (PDF, 419KB)
Download a vision claim form for members using an out-of-network provider.
Life Insurance Claim Form (PDF, 464KB)
Use this for clients with life insurance that require a Proof of Death claim form.
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Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.