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1. Click on the underlined form you wish to print

1. Enter your Producer Information,
* indicates a required field

2. The item will pop up in Adobe Acrobat Reader

2. Select the form(s) by entering the amount you wish to order in the adjacent box (A maximum of 50 for each item is allowed)

3. To print, click File, Print or click on the printer icon in the menu bar

3. Click the SUBMIT button below

4. Make sure all pages are printed, legible and complete (pages are numbered)

Producer Name or Business:*

Producer Code:*
(tax ID or SSN#)

Address:*
(include suite number)

City/State:*

Zip Code:*

Phone #:*

( ) -

Fax #:

e-mail:*

Underlined forms are available to print Now.
Temporary Medical Coverage		GENERAL SUPPLIES
Quantity	Title & Form Number	Quantity	Title & Form Number
	SelecTEMP PPO Application - 30272		Dependent Age Expansion Requirement PA 95-958 (Under 65 Buckslip) - 31524*
	SelecTEMP PPO Outline of Coverage - 30283		PPO Hospital Listing (Under 65) - 30103
	SelecTEMP PPO Salespack– 30306		BlueChoice Hospital Listing - 30170
INDIVIDUAL/FAMILY PRODUCTS			Conditional Receipt/Automatic Payment Authorization Form - 30443
Quantity	Title & Form Number		BCBSI Replacement Form (Under 65) - OB1935
	Product Guide - 30025		Preliminary Underwriting Opinion (for Individual/Family and Children's Products) - 30197*
	Claim Form Return Envelope - OB2149		Claim Form (all Series II & III Products) - 30176
	Supply Requisition Form - 30046		A.M. Best Rating Report(BCBSIL)*
	Request for Mellon HSA 30259*		Standard Authorization Form to Use/Disclose Protected Health Information (PHI) - 31160*
	Mellon Brochure 30262*		Producer Guide to List Bill - 30289
			Personal Health Insurance Certification for Employers - 30290
	BlueEdge Individual HSA Outline of Coverage – 30206		Personal Health Insurance Certification for Employees - 30291*
	BlueEdge Individual HSA 5000 Outline of Coverage – 30207		List Bill Transmittal - 30292
	HSA Sales Pack – 30249		Guide to List Bill for Employers - 30293
	HSA Sales Guide – 30251		Series II Application for Change in Coverage - 31370
	HSA Mailer – 30261		Series III Application for Change in Coverage - 31371
	SelectBlue/SelectBlue Advantage/ BlueValue/BlueValue Advantage Sales Pack - 30155
	BlueChoice Select/BlueChoice Value Salespack - 30156
	Traditional Blue Sales Pack - 30226*
	BasicBlue Sales Pack - 30333* Note: All Sales Packs include (1) Application, (1) Replacement Form, and Outline(s) of Coverage
	Plan Comparison Guide - 30026
	SelectBlue Mailer - 30225
	Product Comparison Chart - 30184
	SelectBlue Advantage Mailer - 30160
	BlueValue Mailer - 30108
	BlueValue Advantage Mailer - 30161
	Combo Mailer - 30171
	BlueChoice Combo Mailer - 30162
	Individual/Family Rate Book - 30048
	SelectBlue Outline of Coverage - 31243
	SelectBlue Advantage Outline of Coverage - 30133
	BlueValue Outline of Coverage - 31242
	BlueValue Advantage Outline of Coverage - 30134
	BlueChoice Select Outline of Coverage - 30131
	BlueChoice Value Outline of Coverage - 30132
	Traditional Blue Outline of Coverage - 31247
	BasicBlue Outline of Coverage - 31248
	Individual/Family Application (All Products) - 31315
	BlueExtras Brochure - 31400
	*Please print or download brochure - available online only
	BlueCare Dental PPO
	Why Choose BlueCare Dental PPO Flier - 01995
	Dental Application (for existing members) - 31441
	Dental BlueCare PPO Outline of Coverage - 31440
	BlueCare Dental PPO Sales Pack - 31521

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