Ct Ged Transcripts Form – Fill Out and Use This PDF

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.

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

*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)

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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.

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).

WillyoubecancelingthiscoverageifapprovedforBlueCrossandBlueShieldofGeorgiacoverage?

▫ Yes ▫ No

Note:PleasemakeacopyofthesignedapplicationforyourrecordspriortosubmittingtoBlueCrossandBlueShieldofGeorgia.

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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.

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

5.	Congenital (birth) or Developmental Disorders			6.	Eyes, Ears, Nose and Throat Disorders
	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. Autism				▫ A. Allergiesincludinghayfever	▫ H. Glaucoma
	▫ B. CerebralPalsy				andrhinitis	▫ I. Hearinglossorcochlear
	▫ C. Cleftpalateand/orlip				▫ B. Cataracts	implants
	▫ D. Mentalretardation				▫ C. Detachedretina	▫ J. Problemswithtonsils
						oradenoids
	▫ E. Othercongenitalordevelopmentaldisorders				▫ D. Deviatednasalseptumor
					polyps	▫ K. Othereyes,ears,nose
	▫ F. NO to all congenital or developmental disorders
					▫ E. Earinfections(morethan	orthroatproblems
					2inthelast12months)	▫ L. NO to all eyes, ears,
					▫ F. Sinusinfections(morethan	nose and throat
						problems
					2inthelast12months)
					▫ G. Eyeinfectionsotherthan
					pinkeye
7.	Kidney or Bladder Problems			8.	Nervous, Mental, Emotional or Behavioral Health
	Within the last FIVE years, has any applicant been diagnosed with				Problems
	or received treatment for any of the following conditions:				Within the last FIVE years, has any applicant been diagnosed with
	▫ A. Bladderinfections				or received treatment for any of the following conditions:
	▫ B. PyelonephritisorKidneyinfection				▫ A. Alcohol abuse	▫ I. PanicDisorder
	▫ C. Kidneyfailure				▫ B. Drug abuse	▫ J. Schizophrenia
	▫ D. Dialysis				▫ C. Attention Deficit Disorder	▫ K. Othermentalhealth
	▫ E. Kidneystones				(ADD/ADHD)	problems
	▫ F. Urinarytractinfectionsorproblems				▫ D. Bipolar Disorder	▫ L. NO to all nervous,
	▫ G. Otherkidneyorbladderproblems				▫ E. Obsessive Compulsive	mental, emotional or
						behavioral health
	▫ H. NO to all kidney or bladder problems				Disorder
						problems
					▫ F. Depression
					▫ G. Anxiety
					▫ H. EatingDisorder
9. Male or Female Reproductive Problems				10. Heart, Blood and Blood Vessel Problems
	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. Cystonovaryorproblems	▫ G. Herpesorgenitaloranalwarts			▫ A. Anemia	▫ K. Highbloodpressure
	withovaries	▫	H. Impotenceorerectile		▫ B. Sicklecellanemia	(Hypertension)
	▫ B. Uterinefibroids		dysfunction		▫ C. Hemophilia	▫ L. Highcholesterolor
						triglycerides
	▫ C. EndometriosisorPelvic	▫ I. Disordersofthetesticle			▫ D. Leukemia
	InflammatoryDisease					▫ M. Raynaud’sdisease
		▫	J. Prostateproblems		▫ E. Heartmurmurorirregular
	▫ D. Infertility(problemsgetting					▫ N. Varicoseveins
		▫	K. Otherfemaleormale		heartbeat
	pregnantorinvitro
			reproductiveproblems		▫ F. Aneurysm	▫ O. Pacemaker
	fertilization)
		▫	L. NO to all male or female		▫ G. Angina(ChestPain)	▫ P. Otherheart,bloodorblood
	▫ E. Abnormalpapsmearor
			reproductive problems			vesselproblems
					▫ H. Bloodclotsorphlebitis
	mammogram
						▫ Q. NO to all heart, blood
	▫ F. Sexuallytransmitteddisease				▫ I. Heartdiseaseorheartattack
						and blood vessel
	suchasHPV(Human				▫ J. Heartvalvediseaseor
						problems
	PapillomaVirus)				disorder

Note:PleasemakeacopyofthesignedapplicationforyourrecordspriortosubmittingtoBlueCrossBlueShieldofGeorgia.

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

	11. Metabolic, Immune System and Endocrine Problems		12. Skin Problems
	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. HIV,AIDSorAIDSrelatedcomplex		▫ A. Acne
	▫ B. Diabetesorhighbloodsugar		▫ B. Psoriasis
	▫ C. Hormoneorgrowthhormonedisorders		▫ C. Rosacea
	▫ D. LupusorSLE(SystemicLupus)		▫ D. Eczemaordermatitis
	▫ E. Thyroidoradrenaldisorders		▫ E. Fungalinfections
	▫ F. Scleroderma		▫ F. Recurringorunresolvedskinlesions(sores)
	▫ G. Gaucher’sdisease		▫ G. Keratosis
	▫ H. Othermetabolic,immunesystemandendocrineproblems		▫ H. Severeburns
	▫ I. NO to all metabolic, immune system and endocrine problems		▫ I. Shingles
			▫ J. Otherskindisorders
			▫ K. NO to all skin problems
	13. Stomach, Intestinal and Liver Problems		14. Unexplained Problems or Symptoms in the last year
	Within the last FIVE years, has any applicant been diagnosed with		Within the last 12 MONTHS, has any applicant had any of the
	or received treatment for any of the following conditions:		following signs or symptoms for which you have not seen a doctor
	▫ A. Colitis	▫ L. HepatitisC,D,orE	or other healthcare provider:
	▫ B. Chronicdiarrhea	▫ M. Hepatitis – typeunknown	▫ A. Chestpain
	▫ C. Irritablebowelsyndrome(IBS)	▫ N. Hernia	▫ B. Dizziness
	▫ D. Colonpolyps	▫ O. Jaundice	▫ C. Lossofconsciousness/blackouts
	▫ E. Crohn’sdisease	▫ P. Liverdisease/cirrhosis	▫ D. Paininback,abdomen(stomach)orpelvis
	▫ F. Gallstonesorgallbladder	▫ Q. Pancreatitis	▫ E. Numbnessortinglinginthelimbs
	disorder	▫ R. Ulcers	▫ F. Abnormalorrecurrentbleeding(notrelatedtomenstruation)
	▫ G. Diverticulitisordiverticulosis
		▫ S. Obesitysurgery	▫ G. Shortnessofbreathortroublebreathing
	▫ H. GERD(Gastroesophageal
		▫ T. Constipation	▫ H. Lumporunexplainedgrowth
	Reflux,orAcidReflux)
		▫ U. Otherstomach,intestinal	▫ I. Tirednessthatdoesnotgoaway
	▫ I. Hemorrhoids
		orliverproblems
			▫ J. Weightlossofmorethan10poundsforreasonsotherthan
	▫ J. HepatitisA	▫ V. NO to all stomach,
			aweightlossprogram
	▫ K. HepatitisB	intestinal and liver
			▫ K. NO to all unexplained problems or symptoms
		problems

STEP 1 (continued) - Allquestionsmustbeansweredortheapplicationwillbereturned.

GIVE COMPLETE DETAILS IN STEP 2 FOR ANY LIFESTYLE OR OTHER QUESTIONS 15 - 24 ANSWERED "YES."

Lifestyle Questions

Note:PleasemakeacopyofthesignedapplicationforyourrecordspriortosubmittingtoBlueCrossandBlueShieldofGeorgia.

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

STEP 1 (continued) - Allquestionsmustbeansweredortheapplicationwillbereturned.

GIVE COMPLETE DETAILS IN STEP 2 FOR ANY LIFESTYLE OR OTHER QUESTIONS 15 - 24 ANSWERED "YES."

Other Questions

YES NO

STEP 2 - Prescription Medications

List ALL medications taken within the last 12 MONTHS by any applicant listed on this application. Use an additional sheet of paper if necessary. All additional pages must be signed and dated by the primary applicant.

			Illness for which	Date	Date
			Medication is	Prescribed	Discontinued	Name, Phone No.
	Applicant Name	Medication/Dosage/Frequency	Prescribed	(mm/dd/yyyy)	(mm/dd/yyyy)	of Physician or Hospital
	Example:	Amoxicillin250mg	Tonsillitis	08/01/2008	09/01/2008	Name: Dr. John Doe
	Mary	4xday				Phone: 555-555-1000
						Name: _____________________
						Phone: _____________________
						Name: _____________________
						Phone: _____________________
						Name: _____________________
						Phone: _____________________
						Name: _____________________
						Phone: _____________________
						Name: _____________________
						Phone: _____________________
						Name: _____________________
						Phone: _____________________
	▫ Please check box if an additional sheet(s) of paper has been completed for this section.

Note:PleasemakeacopyofthesignedapplicationforyourrecordspriortosubmittingtoBlueCrossandBlueShieldofGeorgia.

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

STEP 2 (continued) - Health History

Givecompletedetailsbelowforallselectedcheckboxesotherthanthe“NOtoall”checkboxesforquestions1-14andallLifestyleorOtherquestionsanswered"YES" (seeexamplebelow). Notprovidingcompletedetailswilldelaytheapplicationprocess. Useanadditionalsheetofpaperifnecessary. Alladditionalpagesmustbesigned anddatedbytheprimaryapplicant.

Name & Dosage of

Duration of

Was

Description

Medication &

Condition

Surgery

of Surgery/

Patient

Name of Hospital,

Specific

Dates of Use

Performed?

Procedures

Still

& Date(s)

Question

First

Clinic and/or Person

Diagnosis &

Begin

End

Begin

End

YES

NO

Under

Number

Name

Providing Care

Treatment

(mm/yyyy)

(mm/yyyy)

(mm/yyyy)

(mm/yyyy)

(mm/yyyy)

Treatment

Amoxicillin250mg

Example:

4xday

✓

Tonsillectomy

#6

Mary

Dr. JohnDoe

Tonsillitis

08/2008

09/2008

▫

▫

09/2008

▫

08/2008

09/2008

▫

▫

▫

▫

▫

▫

▫

▫

▫

▫

▫

▫

▫

▫

▫

▫

▫

▫

▫

▫

▫

▫

▫

▫

▫

▫

▫

▫

▫

▫

▫ Please check box if an additional sheet(s) of paper has been completed for this section.

Note:PleasemakeacopyofthesignedapplicationforyourrecordspriortosubmittingtoBlueCrossBlueShieldofGeorgia.

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SectionJ – BillingOptions

INITIAL PREMIUM (required)
▫ CheckEnclosed (Ifpayingbycheck,makethecheckpayable	Total amount enclosed/charged: $
toBlueCrossandBlueShieldofGeorgia.)
▫ CreditCard(seebelow)

METHOD (selectone)

▫BILL TO HOME—Billswillbesenttoyourhomeaddressunlessaseparatebillingaddressislistedbelow.

▫BILL TO OTHER

▫AUTOMATIC BANK DRAFT (automaticpremiumwithdrawalstobeginsecondmonth)—yourpremiumwillbedeductedon,oraboutthe5thofeachmonth. (Youmayattacha blank voidedcheckorcompletetheinformationbelow.)

IauthorizeBlueCrossandBlueShieldofGeorgiatoinitiatepremiumdeductionsfromthecheckingaccountindicatedandthedesignatedfinancial institutiontodebitthesameaccount. IunderstandthatthisauthorizationisineffectuntilInotifyBlueCrossandBlueShieldofGeorgiathatIno longerdesirethisservice,allowingthemreasonabletimetoactuponmynotification. IunderstandBlueCrossandBlueShieldofGeorgiaandmy financialinstitutionhavetherighttodiscontinuethewithdrawalsiftheywishtodoso. Iunderstandthataservicechargewillbeincurredforany withdrawalnothonored.

AccountHolderName(pleaseprint)		AccountHolder’sSSN
AccountHolderSignature(ifotherthantheapplicant)		Date(mm/dd/yyyy)
X
NameofBank	RoutingNumber	AccountNumber

▫IF PAYING BY CREDIT CARD: Acreditcardcanbeusedforthe Initial Premium payment only.

Credit card information

If applicant is using the credit card of another cardholder: Bysigningthisform,applicantrepresentsandwarrantsthathe/shehasthecardholder'sauthorization tousethiscardand,ifnot,thathe/shewilltakefullresponsibilityforthispaymentandanychargesaccruingtoit.

Authorization:

IauthorizeBlueCrossandBlueShieldofGeorgiatochargemyVISA,MasterCard,orDiscovercreditcardfortheinitialpremiumpayment. Iftheresultsofthehealth underwritingformypolicyresultinadifferentpremiumthanmyoriginalpremiumquote,IalsoauthorizeBlueCrossandBlueShieldofGeorgiatochargemyVISA, MasterCard,orDiscovercreditcardforthisdifferenceifnecessary.

IagreethatBlueCrossandBlueShieldofGeorgiaisfullyprotectedinhonoringanycreditcardpayments. Ifurtheragreethatifanycreditcardpaymentisdishonored, withorwithoutcause,intentionallyorinadvertently,BlueCrossandBlueShieldofGeorgiaisundernoliabilitywhatsoever,includinganyfeesimposedbymybank, ifmycreditcardisrejectedeventhoughsuchdishonorresultsinterminationofcoverage.

Applicantsignature:

X

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Section K – Significant Terms, Conditions and Authorizations (TERMS)

Pleasereadthissectioncarefullybeforesigningtheapplication.

1.CURRENT HEALTH COVERAGE: If you currently have health coverage, we strongly recommend that you maintain your current coverage and request an effective date of 75 days from the date of application. This willhelp ensure that your application is processed before you surrender your present insurance.

2.I understand that it is mandatory that I notify Blue Cross and Blue Shield of Georgia(BCBSGA) in writing, immediately if I (the applicant) or any other person for whom coverage is sought received medical treatment, advice,care or a diagnosis for any illness, injury or condition after the date I sign this application but before the coverage effectivedate or the date underwriting approves, whichever is later. I understand that in this situation, BCBSGA has the right to underwrite my application again, using the new information and that, as a result, my coverage/family members’ coverage might be delayed or reformed or, for applicants age nineteen (19) and older, benefits denied due to the illness, injury or condition being treated as a preexisting condition.

3.I understand that sending my initial premium with this application, and the receipt of my payment by Blue Cross and Blue Shield of Georgia, does not mean that coverage has been approved. I may not assign any payment under my Blue Cross and Blue Shield of Georgia program. I am applying for the coverage selected on this application. I understand that any premium quote provided is preliminary and review of my application by medical underwriting may change the premium or result in a denial of coverage. I understand that, to the extent permitted by law, Blue Cross and Blue Shield of Georgia reserves the right to accept or decline this application, and that no right whatsoever is created by this application. I understand that if my application is denied, my bank account or credit card will not be charged.

4.For applicants age nineteen (19) and older, I understand that preexisting conditionsare limited to 12 months after enrollment for conditions in existence within 12 months immediately prior to my enrollment for which medical advice, diagnosis, care or treatment was recommended or received. Pregnancy is considered a preexisting condition.

5.I am responsible to timely notify Blue Cross and Blue Shield of Georgia of any change thatwould make me or any dependent ineligible for coverage.

6.I understand Blue Cross and Blue Shield of Georgia may convert my payment by checkto an electronic Automated Clearinghouse (ACH) debit transaction and that my original check will be destroyed. The debit transaction will appear on my bank statement although my check will not be presented to my financial institution or returned to me. This ACH debit transaction will not enrollme in any Blue Cross and Blue Shield of Georgia automatic debit process and will only occur each time I send a check to Blue Cross and Blue Shield of Georgia. Any resubmissions due to insufficient funds may also occur electronically. I understand that all checking transactions will remain secure, andmy payment by check constitutes acceptance of these terms.

7.I understand I am applying for individual health coverage which is not part of any employer-sponsored plan. I understand that I am responsible for 100% of the premium payment and I am also responsible to ensure that premiums are paid.

8.I understand that my domestic partner, if applicable, is only eligible for coverage if: he or she has been my sole domestic partner for 6 months or more; he or she is at least 18 years of age; he or she is mentally competent; he or she is not related to me in any way (including by blood or adoption) that would prohibit us from being married under state law; he or she is not married to or separated from anyone else; and he or she is financially interdependent with me.

9.If I purchase the optional BlueChoice® Dental coverage, I understand that I will have a six month waiting period forcoverage of Basic Dental Care and a twelvemonthwaitingperiodforcoverageofMajorDentalCare. (ForadescriptionofPreventiveandDiagnostic,Basic,andMajorDentalCareservices pleaserefertoyourmarketingmaterials.)

10.IftheplanIpurchaseoffersamaternityrider,andIpurchasethatmaternityrider,Iunderstandthat1)thesebenefitsapplyonlytome,mycovered

spouseormycovereddomesticpartnerandnottoanydependentchildand2)thesebenefitswillnotbeginuntilaftermymembershiphasbeenineffect

for12months.

11.BysigningthisapplicationIcertifythatIunderstandthatIaloneamresponsibleforreadingandaccuratelycompletingthisapplication,andImust communicateanychangestomystatus. IfIhaveselectedtermlifecoverage,IunderstandthatIamprovidingtheinformationonthisapplicationtothe underwritingdepartmentofGreaterGeorgiaLifeInsuranceCompany(GGL).

12.IacknowledgethatIhavereadtheSignificantTerms,Conditions,andAuthorizations,andIacceptsuchprovisionsasaconditionofcoverage. Ihereby representandagreethatalltheanswersandstatementsinthisrequestarefull,completeandtrue,tothebestofmyknowledgeandbelief,andunderstand thesesaidanswersandstatementsformthebasisuponwhichinsurancewillbemadeeffective. Anyact,practice,oromissionthatconstitutesfraudor intentionalmisrepresentationofmaterialfactfoundinthisapplicationmayresultindenialofbenefits,rescission,orcancellationofmycoverage(s).

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

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Section K – Significant Terms, Conditions and Authorizations (TERMS) (continued)

Any person who knowingly and with intent to defraud any insurance company, health maintenance organization, self-insured plan, or other person, files an application for insurance containing any materially false information or conceals, for the purpose of intentionally misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

I hereby acknowledge that Blue Cross and Blue Shield of Georgia (BCBSGA) has informed me of the following prior to my enrollment in their health care coverage plan:

·number, mix and location of participating/network health care providers

·limitations of choices of participation/network health care providers

·disclosure of contractual relationship between participation/network provider and BCBSGA.

I give this authorization for and on behalf of any eligible dependents and myself ifcovered by Blue Cross and Blue Shield of Georgia. I am acting as their agent and representative.

This application may only be altered solely by the applicant or with his or her writtenconsent.

PrintednameofApplicant

SignatureofApplicant*orLegalRepresentative

DateofBirth

DateSigned

		X	/	/	/	/
	PrintednameofSpouseorDomesticPartner	SignatureofSpouseorDomesticPartnerorLegalRepresentative	DateofBirth		DateSigned
HERE		X	/	/	/	/
SIGN
	PrintednameofDependentChildover18	SignatureofDependentChildover18	DateofBirth		DateSigned
		X	/	/	/	/
	PrintednameofDependentChildover18	SignatureofDependentChildover18	DateofBirth		DateSigned
		X	/	/	/	/
	*(orCustodialParent’sorGuardian'ssignatureifapplicantisunderage18)

Section L – Agent Certification

1.	Are you aware of any information not disclosed on this application relating to the health
	of any person listed on this application that may have a bearing on underwriting?	▫ Yes	▫ No
2.	Didyouseetheproposedsubscriber(andspouse/domesticpartner,ifapplying)atthetime
	thisapplicationwasexecuted?	▫ Yes	▫ No

If NO, please explain: ____________________________________________________________________________________________

3.I certify to the best of my knowledge and belief, the responses herein are accurate.

Agent Signature

Date

X

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

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Authorization for Use of Protected Health Information

PrintednameofApplicant

SignatureofApplicant*orLegalRepresentative

DateofBirth

DateSigned

		X		/	/	/	/
	PrintednameofSpouseorDomesticPartner	SignatureofSpouseorDomesticPartnerorLegalRepresentative		DateofBirth		DateSigned
HERE		X		/	/	/	/
SIGN	PrintednameofDependentChildover18	SignatureofDependentChildover18		DateofBirth		DateSigned
		X		/	/	/	/
	PrintednameofDependentChildover18	SignatureofDependentChildover18		DateofBirth		DateSigned
		X		/	/	/	/
*(orCustodialParent’sorGuardian'ssignatureifapplicantisunderage18)
Designated Legal Representative/Guardian
Ifalegalrepresentativesignsonbehalfoftheapplicantorspouseordomesticpartner,acopyofthelegalrepresentative’sauthoritymustbeattachedtotheapplication.
Legal Representative (please print full name)			Legal Relationship to Individual

Aphotocopyofthisformwillbeasvalidastheoriginal. YouoranauthorizedrepresentativehavetherighttoreceiveacopyofthisAuthorizationuponrequest.

	Blue Cross and Blue Shield of Georgia, Inc., Blue Cross Blue Shield Healthcare Plan of Georgia, Inc., and Greater 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 Shieldnames
F-1681-V08GA(Rev. 9/10)	and symbols are registered marks of the Blue Cross and Blue Shield Association.	Page12of13

Conditional Receipt

THIS RECEIPT DOES NOT PROVIDE ANY COVERAGE UNTIL ALL THE TERMS AND CONDITIONS LISTED BELOW ARE MET.

Blue Cross and Blue Shield of Georgia (BCBSGA) has received from the named Applicant an advance deposit equal to the first month’s dues together with an application for designated health insurance coverage. Such payment is acceptedsubject to the following conditions:

Subject to the provisions of the contract, the coverage applied for will be effectivefrom, and the contract date as of, the day following acceptance by Medical Underwriting, unless otherwise specifically stated, provided that the paymentevidenced by this receipt is the full first month’s dues and provided that BCBSGA determines that as of the date of the application all proposed covered persons were acceptable for coverage and for the benefits applied for. If the application is not approved by BCBSGA said Plan shall incur no liability and the payment evidenced by this receipt will be refunded to the applicant. No one has the authority to waive or modify any of the terms or conditions of this receipt.

If you do not receive a contract within 60 days, please contact Blue Cross and Blue Shieldof Georgia Customer Service at (800)718-8831 or Post Office Box 7368, Columbus, Georgia 31908-7368.

Abbreviated Notice Of Insurance Information Practices

PRIVACY ACT. Georgia state law establishes standards for the collection, use and disclosureof information gathered in connection with insurance transactions. The application attached to this notice contains specific personal questions about you and your dependents. We need your answers to decide if you qualify for coverage. We are required to advise you that personal information may be collected from persons other than you or other individuals proposed for coverage. An investigative consumer report may be made to help usobtain additional medical data from physicians or hospitals.

ALL DATA CONFIDENTIAL. Official Code of Georgia, code section 33-39-5, subsection (c) (1 through 4) requires that:

1.Personal information may be collected from persons other than the individual or individuals proposed for coverage;

2.Such information as well as other personal or privileged information subsequently collected by the insurance institution or agent may in certain circumstances be disclosed to third parties without authorization;

3.A right of access and correction exists with respect to all personal information collected;

4.The notice prescribed in subsection (b) of the above referenced Code sectionwill be furnished to the applicant or policyholder upon request.

ACCESS TO YOUR DATA. You have the right to see or obtain a photocopy of your personal informationwhich we have. You also have the right to send us a written request if you want any of your personal information to be amended,corrected or deleted. If you wish to have a more detailed explanation of our information practices, please contact Blue Cross and Blue Shield of Georgia Customer Service at (800)718-8831 or Post Office Box 7368, Columbus, Georgia 31908-7368.