Products Being Purchased:
Requested Effective Date of Coverage:
1/1/2010 12:00:00 AM
Requested Billing Cycle:
Initial Renewal Date:
1/1/2011 12:00:00 AM
Employer Contribution Percent Toward Premium:
Employer’s Legal Name:
Fiscal Year Begins on (MM/DD):
Fiscal Year Ends on (MM/DD):
Benefits are based on:
Nature of Business:
Nature of Business
Health Benefit Plan Name:
Health Benefit Plan Name
Does the Employer have any current group coverage with BlueCross BlueShield of Tennessee?
Current Group Medical Carrier:
Are there Subsidiaries under this Group Agreement?
Address Line 1: 11333 N. Scottsdale Road
Address Line 2: Ste 1003
City: Paradise Valley
Physical Address Same as Mailing Address:
Billing Address Same as Mailing Address:
Extension (if applicable):
Executive Decision Maker
Same As Group Administrator?
Federal Employer Identification Number (FEIN):
Legal Entity Type:
Total number of current employees (full-time, part-time, owners/partners, private contractors):
Total number of employees who work a minimum of 30 hours per week (include owners/partners):
Total number of employees in preceding year:
Does the Employer’s Plan qualify as an ERISA Plan?
Is this Coverage part of a Union negotiated Contract?
Is this Employer a Minority Owned Business?
Is this Employer a Government Contractor?
In the past 36 months, has any creditor filed a petition requesting the Employer or any affiliated entity to be placed into bankruptcy?
In the past 36 months, has the Employer or any affiliated entity filed for protection or operated under Federal or State bankruptcy laws?
ID Card/Web Information
ID Card Information
Initial ID Cards are to be mailed to:
Future ID Cards are to be mailed to:
Enrollment changes via the Web are to be Accepted from:
Employee Address Changes via the Web are to be Accepted from:
Coordination of Benefits via the Web are to be Accepted from:
Optional Medical Coverages
Include in Option: 1
Behavioral Health Rider: No
Wellcare Rider: No
Accept with initial notification letter
Will BCBST handle COBRA Administration for non-BCBST Product(s)?
Are you offering a BCBST HRA?
Are you offering a BCBST FSA?
Do you contribute to an HSA?