Ct Ged Transcripts Form PDF Details

Embarking on a journey toward securing health insurance coverage can be an intricate process, filled with various steps and necessary documents. Among these prerequisites is the completion of the Georgia Individual Enrollment Application, a comprehensive form designed to gather critical information for those seeking new coverage or alterations to their existing Blue Cross Blue Shield of Georgia (BCBSGA) policy. Applicants are required to diligently fill out sections ranging from personal information, including residency and citizenship status, to detailed health history inquiries meant to assess eligibility and the scope of coverage needed. Additionally, this form opens up avenues for applicants to elect for additional benefits such as dental and term life insurance coverage, ensuring a holistic approach to their health insurance needs. The decision-making process is further facilitated through a selection of medical coverage plans and optional riders, allowing applicants to tailor their coverage according to their specific health and financial considerations. Importantly, the form stresses the necessity of honest and comprehensive disclosure of medical history to prevent any potential rescission of coverage. This thorough and structured approach exemplifies BCBSGA's commitment to providing customizable and inclusive health insurance solutions to residents of Georgia, echoing the complexities and individual needs inherent in healthcare insurance planning.

QuestionAnswer
Form NameCt Ged Transcripts Form
Form Length13 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min 15 sec
Other namesatlanta tech ged transcript, ged templates to edit, ged testing, printable ged certificates

Form Preview Example

Georgia

Individual Enrollment Application

Please complete in blue or black ink only. Do not write in shaded areas, these are for internal use only.

Section A – Coverage Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Application Type (select one):

New Coverage

 

 

Change BCBSGA Individual policy coverage - Policy No.

________________________

 

 

 

 

 

 

 

 

Add dependent(s) to current coverage - Policy No. ___________________________

 

 

 

 

 

 

 

 

Effective date requested:

Ifyourapplicationisapproved,yourcoveragecanstartonanydayofthemonthafterthedatewereceiveyourapplication.The

 

 

 

 

requestedeffectivedateisnotaguaranteethattheeffectivedatewillbetherequesteddateintheeventweagreetoprovidecoverage.

 

 

 

 

Please choose the date you would like your coverage to start:_______/_______/___________ MM/DD/YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section B – Applicant Information (Applicant must be oldest adult member.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

FirstName

 

 

 

 

 

MI

 

SocialSecurityNumber*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HomeAddress(streetandP.O. Boxifapplicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

State

 

Zip

 

 

 

 

County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MaritalStatus

 

 

 

 

 

Height(Ft./In.)

 

Weight

 

Sex

 

Age

DateofBirth

Single

Married

DomesticPartner

 

 

 

/

 

 

 

 

 

M F

 

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DaytimePhoneNumber

EveningPhoneNumber

 

 

 

E-mail Address*:

 

 

 

 

 

 

 

 

 

(

)

 

 

(

)

 

 

 

Ifpossible,doyouwantE-mailnotification? .................... Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AreyoualegalresidentoftheUnitedStatesandaresident

 

 

 

LanguageChoice(Optional)

 

 

 

 

 

 

ofthestateofGeorgia?

Yes

No

English

Spanish

Korean

Chinese(C/M)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are all applicants listed on this application United States citizens?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

IfNO,who? ___________________________________ andhowmanymonths/yearshavetheyresidedintheUnitedStates? _____ yearsand _____ months

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section C – Spouse or Domestic Partner to be Covered Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LastName

 

 

 

 

 

FirstName

 

 

 

 

 

MI

 

SocialSecurityNumber*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship

 

 

Height(Ft./In.)

 

Weight

 

 

Sex

 

 

Age

 

DateofBirth

 

 

 

Spouse

DomesticPartner

 

/

 

 

 

 

 

 

M

F

 

 

 

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AreyoualegalresidentoftheUnitedStatesandaresident

 

 

 

LanguageChoice(Optional)

 

 

 

 

 

 

ofthestateofGeorgia?

Yes

No

English

Spanish

Korean

Chinese(C/M)

 

 

 

 

 

 

 

 

 

 

 

 

Section D – Child Dependents to be Covered Information (Allfieldsrequired. Attachaseparatesheetifnecessary.)

 

 

 

 

 

 

 

 

 

 

 

Dependentinformationmustbecompletedforalladditionalchilddependents(ifany)tobecoveredunderthiscoverage. Aneligibledependentmaybeyourchildren,oryour

spouseordomesticpartner’schildren(totheendofthecalendarmonthinwhichtheyturn26). (Listalldependentsbeginningwiththeeldest.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First,MI

 

 

SocialSecurity

 

Sex

 

Age

 

 

DateofBirth

Height

 

Weight

 

(lastnameifdifferent)

 

 

Number*

 

 

 

 

 

 

 

mm/dd/yyyy

Ft. /In.

 

Lbs.

 

 

 

 

 

 

 

 

 

M

F

 

 

 

 

/

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

F

 

 

 

 

/

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

F

 

 

 

 

/

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

F

 

 

 

 

/

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

F

 

 

 

 

/

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Thisinformationisusedforinternalpurposesonly.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Blue Cross and Blue Shield of Georgia, Inc., Blue Cross Blue Shield Healthcare Plan of Georgia, Inc., andGreater Georgia

 

Life Insurance Company are independent licensees of the Blue Cross and Blue Shield Association. Life and Disability

 

products underwritten by Greater Georgia Life Insurance Company. The Blue Cross and Blue Shield names

F-1681-V08GA(Rev. 9/10)

and symbols are registered marks of the Blue Cross and Blue Shield Association.

MGAFR0870G

Page1of13

Section E – Medical Coverage (Selectplan,deductible,andoptionalridersbelow.)

BCBSGA will enroll all eligible family members unless otherwise instructed below.

I,theApplicant,requestthatBCBSGAnotenrollanyeligibleapplicantsunlessALLfamilymembersqualify.

Premier Plus POS

$750EK

$1,500EL

$2,500EM

$3,500EN

$5,000EO

$7,500EP

 

$10,000EQ

$20,000ER

 

 

 

 

 

ConsumerChoiceOption

MaternityRider*

 

 

Premier Plus PPO

$750FI

$1,500FJ

$2,500FL

$3,500FM

$5,000FN

$7,500FO

 

$10,000FP

$20,000FQ

 

 

 

 

 

ConsumerChoiceOption

MaternityRider*

 

 

SmartSense Plus POS

$750FA

$1,500FB

$2,500FC

$3,500FD

$5,000FE

$7,500FF

 

$10,000FG

$20,000FH

 

 

 

 

 

ConsumerChoiceOption

EnhancedDrugRider

 

 

SmartSense Plus PP0

$750ES

$1,500ET

$2,500EU

$3,500EV

$5,000EW

$7,500EX

 

$10,000EY

$20,000EZ

 

 

 

 

 

ConsumerChoiceOption

EnhancedDrugRider

 

 

HSA Compatible Plans

SingleForwardFocusHSAPOS(80%coinsurance) ......

SingleForwardFocusHSAPOS(100%coinsurance) .....

FamilyForwardFocusHSAPOS(80%coinsurance) ......

FamilyForwardFocusHSAPOS(100%coinsurance) .....

SingleForwardFocusHSAPPO(80%coinsurance) ......

SingleForwardFocusHSAPPO(100%coinsurance) .....

FamilyForwardFocusHSAPPO(80%coinsurance) ......

FamilyForwardFocusHSAPPO(100%coinsurance) .....

$1,750DI

$3,500DK

$3,500DM

$7,000DO

$1,750DQ

$3,500DS

$3,500DU

$7,000DW

$2,500DJ

ConsumerChoiceOption

MaternityRider*

$5,500DL

ConsumerChoiceOption

MaternityRider*

$5,000DN

ConsumerChoiceOption

MaternityRider*

$11,000DP

ConsumerChoiceOption

MaternityRider*

$2,500DR

ConsumerChoiceOption

MaternityRider*

$5,500DT

ConsumerChoiceOption

MaternityRider*

$5,000DV

ConsumerChoiceOption

MaternityRider*

$11,000DX

ConsumerChoiceOption

MaternityRider*

Yes,IwouldliketoestablishahealthsavingsaccountinconjunctionwiththeHSA-compatiblehealthplanIselectedabove. BlueCrossandBlueShieldofGeorgia (BCBSGA)willprovideyourinformationtoBCBSGA’sbankingpartner. (PleasefillinyoursocialsecuritynumberinsectionB.)

No,IDONOTwanttoestablishahealthsavingsaccountinconjunctionwiththeHSA-compatiblehealthplanIselectedabove.

*Maternity Rider available on deductibles of $2,500 & higher

Section F – Dental Coverage Selection (optional coverage at an additional cost per individual)

BlueChoice® Dental GAD1

Yes,Iwishtoadddentalcoverage. IfYes,selectONEcoveragetype(appliestoindividualslistedonthisapplicationonly):

Applicantonly

Applicant,Spouseandalldependentchildrenlisted

Applicant&alldependentchildrenlisted

Yes,ifmyselforanylistedfamilymemberaredeclinedformedicalcoverage,stillenroll all members selected above, if eligible.

Note:PleasemakeacopyofthesignedapplicationforyourrecordspriortosubmittingtoBlueCrossandBlueShieldofGeorgia.

F-1681-V08GA(Rev. 9/10)

Page2of13

Section G – Greater Georgia Life Insurance Company Term Life Insurance (optional coverage at an additional cost per individual)

Yes, in addition to my medical coverage, I wish to apply for Term Life Insurance. GAL1

 

 

Do you, the applicant, own an existing life policy?

Yes

No

If you answered “Yes” to the above question, inform the agent with whom you are working (if any), who will provide you

 

 

an “Important Notice: Replacement of Life Insurance,” which you must read and complete.

 

 

By applying for this proposed life policy, do you intend to replace, discontinue or change any existing life policy?

Yes

No

Provide information below. Applicants must meet Blue Cross and Blue Shield of Georgia’sUnderwriting Guidelines to qualify for Term Life Insurance Coverage. Applicants under the age of one year are not eligible for Life Insurance. All Term Life policies terminate at age 65.

 

Birthday

Coverage Amount

 

%

 

Social Security

Applicants

(mm/dd/yyyy)

(select one)

Beneficiary**

Allocation

Relationship

Number

 

/

/

$15,000

$75,000*

Primary:

 

 

 

 

$25,000

$100,000*

 

 

 

 

 

Contingent:

 

 

 

 

 

 

$50,000*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

$15,000

$75,000*

Primary:

 

 

 

 

$25,000

$100,000*

 

 

 

 

 

Contingent:

 

 

 

 

 

 

$50,000*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

$15,000

$75,000*

Primary:

 

 

 

 

$25,000

$100,000*

 

 

 

 

 

Contingent:

 

 

 

 

 

 

$50,000*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

$15,000

$75,000*

Primary:

 

 

 

 

$25,000

$100,000*

 

 

 

 

 

Contingent:

 

 

 

 

 

 

$50,000*

 

 

 

 

 

 

 

 

 

 

 

 

 

*Amounts above $25,000 are not available to applicants under the age of 20. If selected by an approved applicant under age 20, the selection will default to $25,000. ** If a beneficiary is not listed and a policy is issued, death benefits will be paid in accordance with the Beneficiary Provision of the Policy.

Section H – Other Health Coverage

AreyouoranyoneapplyingforcoveragecurrentlyeligibleforMedicare?.......................................................................... Yes No

Ifyes,givename. _________________________________________________________________________________________________

AreyouoranyoneapplyingforcoveragecurrentlyreceivingSocialSecurityDisability,Medicare,Medicaidorother

 

governmentprogrambenefits,orunabletoworkduetodisabilityorreceivingWorkers'Compensation?

Yes No

Ifyes,givenameandreason: _________________________________________________________________________________________

_______________________________________________ Startdateofcoverage: ____/____/______ Enddateofcoverage: ____/____/______

Doyou,oranyoneapplyingforcoverage,currentlyhavehealthcarecoverage?

Yes

No

 

 

 

Didyouoryoureligibledependentshavecreditablecoveragewithinthepast63days?(Youmaybeeligibleforpreexistingcredit.

 

 

Preexistingconditionlimitationsdonotapplytoapplicantsundertheageofnineteen(19).)

Yes

No

The following information must be completed in order for credit to be given. Please provide the previous 24 months of coverage.

Name(s)ofcoveredpersons. Ifthewholefamily,simplywriteALLinspacebelow.

IdentificationNumber(s)

Nameandphonenumberofpriorcarrier(s)

Reasonforcancellation

Typeofcoverage

Group

Individual

EffectiveDateofCoverage

 

 

 

 

CancellationDateofCoverage

WillyoubecancelingthiscoverageifapprovedforBlueCrossandBlueShieldofGeorgiacoverage?

Yes No

Complete this section if you’ve had more than one carrier in the last 24 months(attach a separate sheet if necessary).

Name(s)ofcoveredpersons. Ifthewholefamily,simplywriteALLinspacebelow.

IdentificationNumber(s)

Nameandphonenumberofpriorcarrier(s)

Reasonforcancellation

Typeofcoverage

Group

Individual

EffectiveDateofCoverage

 

 

 

 

CancellationDateofCoverage

WillyoubecancelingthiscoverageifapprovedforBlueCrossandBlueShieldofGeorgiacoverage?

Yes No

Note:PleasemakeacopyofthesignedapplicationforyourrecordspriortosubmittingtoBlueCrossandBlueShieldofGeorgia.

F-1681-V08GA(Rev. 9/10)

Page3of13

Section I – Health History - For Each Family Member (IMPORTANT: This section has two steps)

STEP 1 - Allquestionsmustbeansweredortheapplicationwillbereturned.

GIVE COMPLETE DETAILS IN STEP 2 FOR ALL SELECTED CHECK BOXES OTHER THAN THE “NO TO ALL” CHECK BOXES FOR QUESTIONS 1 - 14 BELOW.

When answering questions on this enrollment application the information provided for each individual should include only information about that individual, and should not include any genetic information. Genetic information includes family medical history and information related to the individual's genetic testing, genetic services,genetic counseling, or genetic diseases for which the individual may be at risk. All responses pertaining to an individual will only be considered and applied to the individual in question.

NOTICE: You must provide truthful and complete answers to the following questions to the best of your ability. We are relying on the information you provide to determine whether you are eligible for coverage. If you are unsure of your current medical condition, we strongly recommend that you ask your current or previous physician(s) to clarify your specific condition. We have the right to review all of your medical records to verify the accuracy of your information during the first 24 months you are covered. However, do not assume we will review all of your medical records before approving your application. If we issue coverage to you and then discover an act, practice, or omission that constitutes fraud or intentional misrepresentation of material fact, we may rescind your coverage, even after it has been issued. This means that you may lose your health benefits including coverage for treatment already received. Rescission may occur even if we review your medical records or seek medical confirmation of your health information as part of processing your application. Even if you currently have healthinsurance coverage or had prior coverage with Blue Cross and Blue Shield of Georgia, you must fully disclose and answer all health history questions.

PLEASE NOTE: The health history questions apply to ANY medical advice, diagnosis, care or treatment that you received or that a healthcare provider recommended that you receive for any of the conditions listed.

1. Bone,JointandMuscleProblems

2. BrainandNerveProblems

 

Within the last FIVE years, has any applicant been diagnosed with

Within the last FIVE years, has any applicant been diagnosed with

or received treatment for any of the following conditions:

or received treatment for any of the following conditions:

A. Arthritis(osteo-,rheumatoidorother)

A. Headaches requiring

H. Seizuresorconvulsions

B. Back,neck,muscle,discortendonproblems

prescription medication

I. HeadInjury

 

C. Bursitis

B. Migraines

J. StrokeorTransient

 

D. Gout

C. MS (Multiple Sclerosis)

IschemicAttack(TIA)

 

 

E. Fibromyalgia

D. Alzheimer’s Disease or

K. Otherbrainornerve

Dementia

problem

F. Osteopenia

E. Muscular Dystrophy

L. NO to all brain and

G. AnkylosingSpondylitis

F. Parkinson’sDisease

nerve problems

H. Osteoporosis

 

G. Paralysis

 

I. TMJ(TemporomandibularJoint)disorder

 

 

 

J. Otherbone,jointormuscleproblems

 

 

K. NO to all bone, joint and muscle problems

 

 

 

 

 

3. BreathingorLungProblems

4. Cancer,CystorTumor

 

Within the last FIVE years, has any applicant been diagnosed with

Within the last TEN years, has any applicant been diagnosed with

or received treatment for any of the following conditions:

or received treatment for any of the following conditions:

A. Asthma

A. Cancer

 

B. Bronchitis

B. Basalcell

 

C. COPD(ChronicObstructivePulmonaryDisorder)

C. Squamouscell

 

D. Cysticfibrosis

D. Melanoma

 

E. Emphysema

E. PolyporPapilloma

 

F. Pneumonia

F. Cyst,growth,lump,massortumor

 

G. Sleepapnea

G. Othercancer,cystortumordisorder

H. Tuberculosis

H. NO to all cancer, cyst or tumors

I. Otherbreathingorlungproblems

 

 

J. NO to all breathing or lung problems

 

 

 

 

 

Note:PleasemakeacopyofthesignedapplicationforyourrecordspriortosubmittingtoBlueCrossBlueShieldofGeorgia.

F-1681-V08GA(Rev. 9/10)

Page4of13

How to Edit Ct Ged Transcripts Form Online for Free

ged transcripts can be filled out online effortlessly. Just open FormsPal PDF editing tool to perform the job promptly. To make our editor better and more convenient to utilize, we consistently work on new features, with our users' suggestions in mind. Getting underway is simple! All you should do is stick to the next simple steps down below:

Step 1: Access the PDF form inside our editor by clicking on the "Get Form Button" at the top of this page.

Step 2: As you access the editor, you will get the document all set to be filled in. Other than filling out various fields, it's also possible to perform many other things with the Document, specifically putting on your own textual content, modifying the initial textual content, inserting graphics, affixing your signature to the document, and much more.

As for the blank fields of this particular document, here is what you want to do:

1. You should fill out the ged transcripts correctly, thus pay close attention when filling in the sections comprising these specific blank fields:

Writing part 1 in ged certificate

2. Once this section is finished, you need to add the essential details in Last Name, First Name, Relationship Spouse Domestic, Height FtIn Are you a legal, Weight, Age, Sex, M F, Social Security Number, Date of Birth, Language Choice Optional English, Spanish, Korean, Chinese CM, and Section D Child Dependents to be in order to progress further.

Step no. 2 in filling out ged certificate

3. The following step is related to BCBSGA will enroll all eligible, I the Applicant request that, Premier Plus POS, EQ ER, Consumer Choice Option, Maternity Rider, Premier Plus PPO, Consumer Choice Option, Maternity Rider, SmartSense Plus POS, FG FH, Consumer Choice Option, Enhanced Drug Rider, SmartSense Plus PP, and EY EZ - type in these blanks.

ged certificate completion process clarified (step 3)

People who work with this document generally make errors while completing Consumer Choice Option in this part. Ensure you read twice what you type in right here.

4. To go onward, the next stage requires filling in several form blanks. Examples of these are Single ForwardFocus HSA POS, Consumer Choice Option, Maternity Rider, Single ForwardFocus HSA POS, Consumer Choice Option, Maternity Rider, Family ForwardFocus HSA POS, Consumer Choice Option, Maternity Rider, Family ForwardFocus HSA POS, Consumer Choice Option, Maternity Rider, Single ForwardFocus HSA PPO, Consumer Choice Option, and Maternity Rider, which you'll find integral to moving forward with this PDF.

Learn how to prepare ged certificate stage 4

5. This form needs to be wrapped up by dealing with this area. Below one can find an extensive set of blank fields that need specific information in order for your document usage to be accomplished: Section F Dental Coverage, BlueChoice Dental GAD, Yes I wish to add dental coverage, Applicant only, Applicant Spouse and all, Applicant all dependent children, Yes if myself or any listed, Note Please make a copy of the, FVGA Rev, and Page of.

Filling out part 5 of ged certificate

Step 3: After double-checking the fields and details, press "Done" and you are good to go! Obtain your ged transcripts the instant you register at FormsPal for a free trial. Easily access the pdf document within your FormsPal account, along with any edits and changes being all preserved! Here at FormsPal, we strive to make sure that all your details are maintained private.