Downloadable Forms for 2-50 Employees

BlueAdvantage Entrepreneur
	Form Name	Form Number	Date
Employer Enrollment
	2021 Group Enrollment Application/Change Form	#232320	09/19
	2021 Group Enrollment Application/Change Form – Spanish	#229483	09/19
	2021 Benefit Program Application (BPA)	#IL-SG-HP-BPA	05/20
	2021 Benefit Program Application (BPA)	#IL-SG-HP-BPA	05/20
	2021 Benefit Program Selection (BPS) Form	#GA-RSG 2021-BPS	10/20
	2021 Benefit Program Selection (BPS) Form	#GA-RSG 2021-BPS	10/20
	2020 Benefit Program Application (BPA)	#IL-SG-HP-BPA	05/19
	2020 Benefit Program Application (BPA)	#IL-SG-HP-BPA	05/19
	2020 Benefit Program Selection (BPS) Form	#GA-RSG 2020-BPS	10/19
	2020 Benefit Program Selection (BPS) Form	#GA-RSG 2020-BPS	10/19
	Employer Group Information Form (small group)	#IL Small Group EGI	02/16
	Submission Guidelines for Small Group Health Coverage	#23162	02/11
	HMO/CPO Provider Selection Enrollment and Change Form	#22840	01/11
	Producer/Employer Tips for Submitting New Small Groups Flier	#22018	06/09
	General Notice of Special Enrollment Rights	#22963	04/15
	Notice of Information Practices	#EB4644	03/04
	HIPAA Privacy Practices Notice and Privacy Forms		11/16
	Affidavit of Domestic Partnership	#20551	01/05
	Statement of Termination of Domestic Partnership	#20560	02/07
	Tax Information on Health Benefits for Domestic Partnership	#20559	02/07
	New Business Checklist for SG Regulated	#227019	09/14
	Small Group HCSC/FDL Disclosure Form	#EB4644	07/01
	BAE Product Combination Options	#20946	05/06
	Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions	#240208.0320	03/20
	Information Regarding Medicare Secondary Payer (MSP) Statute	#21091.0609	06/09
	MSP Fact Sheet (380 kb)	#24443.0612	06/12
	Individual Medicare Secondary Payer Form	#20473	10/04
	AD Change Form		11/14
Account Maintenance and Supply Forms
	Group Administrator's Member Transaction Form	#20406	06/10
	Student Certification Form	#23402.0611	06/11
	Dependent Student Medical Leave Certification Form	#23077.0111	01/11
	Disabled Dependent Authorization Form (for Group Plans) – Members with an employer-sponsored health plan should use this form to request continuation of coverage on their existing policy for a dependent who is incapable of self-support because of mental or physical impairment. Mail or fax the completed form to BCBSIL (see address and fax number at the top of the form). You can also use this form to add a disabled dependent to a new policy (include this completed form when you submit your enrollment application).	#238412.0819	08/19
	Producer Supply Requisition Form	#OB3658	12/03
	Enrollment Change Request Form	#22735	06/10
	Medical Claim Form (Domestic) – Members should use this form to request reimbursement for health care services obtained within the United States, a U.S. territory, when on a cruise ship, or on a U.S. military base.	228934.1015	10/15
	Medical Claim Form (Domestic) – Spanish	229421.0116	01/16
	Medical Claim Form (International) – Members should use this claim form to request reimbursement for health care services obtained when traveling internationally – when outside of the United States or a U.S. territory, but NOT for services obtained on a cruise ship or a U.S. military base.	16-581-N35
	Medical Claim Form (International) – Spanish	16-581-N35
	COBRA Election Form
	COBRA Notification Form
	IL Employee Continuation Privilege Election Form	#24056	02/12
	IL Continuation Group Request From	#24044	02/12