Forms and Applications
Broker Resources
Get a quote | Web based enrollment | Medical plans | January 2023 Summary of Benefits | Prescription Drug Options
When providing an application to an applicant or Blue Shield member, you must also include a Notice of Language Assistance.
Fillable PDFs can be saved to your desktop. However, applicants using Acrobat Reader, rather than Acrobat Standard or Pro, will only be able to print the information after it's filled out, not save. If using Standard or Pro, If using Standard or Pro, the filled out information can be saved. If you do not have Adobe Reader or are not able to access these fillable features, download the latest version.
| Form | Download |
|---|---|
| Employee Application Employees should complete this form to enroll in a group medical plan. For employee enrollments to a new or existing employer group. |
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| Medical only Employees should complete this form to enroll in a group medical plan. For employee enrollments to a new or existing employer group. |
Effective 1/1/2023 Effective 1/1/2022 |
| Life Only Employee Application Employees should complete this form to enroll in a group term life policy. For employee enrollments to a new or existing employer group. |
Effective 1/1/2023 Effective 1/1/2022 |
| Medical and Life Employees should complete this form to enroll in a group medical plan, group vision plan or group term life policy. For employee enrollments to a new or existing employer group. |
Effective 1/1/2023 Effective 1/1/2022 |
| Form | Download |
|---|---|
| HIPPAA Release Form Authorization for the release of personal and health information. |
Download |
| Evidence of Insurability | Download |
| Refusal of Personal Coverage Form Employees should complete this form if they, their spouse/domestic partner of dependents are refusing their employer's medical or dental plan coverage. |
Download |
| Declaration of Disability of Over Age Dependent Children For enrolled dependent children who normally lose their eligibility because of age, but who are disabled by reason of a physically or mentally disabling injury. |
English Spanish |
| Subscriber Disability File for an extension of benefits. Administrators must also complete the Notice of Total and Permanent Disability Form. |
Download |
| Disability Addendum | Download |
| Form | Download |
|---|---|
| Standalone Specialty Benefits Employer Application Dental, Vision & Life Insurance |
Download |
| Conversion to Individual Coverage: Group Life | Download |
| Beneficiary Affidavit & Assignment Form | Download |
| Beneficiary Change Request | Download |
| Waiver of Premium Claim Form: Group Life If a member becomes totally disabled, the life premium may be waived |
Download |