Blue Access for Producers

Downloadable Forms for 51-150 Employees


BluePrint/CPO

 

Form Name Form Number Date

Proposal

Request for BluePrint Intermediate Proposal Form  s2r 10/03

Employer Enrollment

BCBSIL Submission form for Small Groups 

23640

09/11

Submission Guidelines for Small Group Health Coverage 

23162

02/11

Small Group Standard Health Application 

#22997, #23071

12/11, 01/11

HMO/CPO Provider Selection Enrollment and Change Form 

#22840

01/11

Producer/Employer Tips for Submitting New Small Groups Flier  #22018 06/09
New Business Checklist  #20910 09/12
Benefit Program Application Form 
(For Accounts Effective 1/1/14 and after)
#IL-LG-51-150-HP-BPA 01/14
Addendum to the Insured BPA Regarding Affiliated Companies  #MGA-10-1-ADD 2007
Benefit Plan Selection Form 
(For Accounts Effective 1/1/14 and after)
#GA-10-9-SMGRP BPSF 01/14
Benefit Plan Selection Form 
(For Accounts Effective 1/1/14 and after)
#GA-10-9-SMGRP BPSF 01/14
Benefit Plan Selection Form 
(For Accounts Effective 1/1/13 and after)
#GA-10-9-SMGRP BPSF 01/13
Benefit Plan Selection Form 
(For Accounts Effective 7/1/12 and after)
#GA-10-9-SMGRP BPSF 07/12
Benefit Plan Selection Form 
(For Accounts Effective 8/1/11 and after)
#GA-10-9-SMGRP BPSF 08/11
Standard Authorization Form and other HIPAA Privacy Forms    
Health Care Account (HCA) Plan Benefit Program Application 
(Applicable to 51-150 Insured Group Accounts)
#G-10-4 HCS SG 08/11
Health Care Account (HCA) Plan Benefit Program Application    08/11
Employer Group Information Form for New Groups  #IL Small Group EGI 01/14
Employer Group Information Form for Renewing Groups  #IL Small Group (Renewals) EGI 01/14
Small Group HCSC/FDL Disclosure Form  #EB4644 03/04
Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions  #21122 09/13
Information Regarding Medicare Secondary Payer (MSP)Statute  #21091.0609 06/09
MSP Fact Sheet  

#24443.0612

06/12

Individual Medicare Secondary Payer Form  #20473 10/04
General Notice of Special Enrollment Rights and Preexisting Condition Exclusion  #225425.0913 09/13
Affidavit of Domestic Partnership  #20551 01/05

Account Maintenance and Supply Forms

2014 Contraceptive Drug List  #225850 12/13
Group Administrator's Member Transactions Form  #20406 06/10
Enrollment Change Request Form  #22735 06/10
Medical Claim Form  #20479 06/07
International Claim Form  #N35-10-118  
COBRA Election Form     
COBRA Notification Form     
IL Employee Continuation Privilege Election Form  #24056 02/12
IL Continuation Group Request From  #24044 02/12
Student Certification Form  #23402.0611 06/11
Dependent Student Medical Leave Certification Form  #23077.0111 01/11
Statement of Termination of Domestic Partnership  #20560 02/07
Tax Information on Health Benefits for Domestic Partnership  #20559 02/07