Agent Alliance ~ FORMS

Note: All of the forms below, Group Enrollment and Coverage Agreements, as well as Benefits at a Glance, are also available to you when you download the most current version of BCBSM's Rating Software ~ Rate Ease.
Download Rate Ease software

BCBSM 2+ Group Enrollment Forms
	New Business Checklist for 2plus Groups
	10/01/09 BCBSM Job Aid
	Group Underwriting Roster
	10/01/09 Community Blue New Group
	10/01/09 Community Blue Benefit Change
	10/01/09 BCBSM BlueCore Plus Benefit Change
	10/01/09 BCBSM BlueCore Plus New Group
	10/01/09 Ancillary Benefit Change
	10/01/09 Flex Blue Benefit Change
	10/01/09 Flex Blue New Group
	10/01/09 Stand Alone Dental New Group
	Dental Roster
	Enrollment & Change of Status Form
	Employee Waiver Form
	Multiple Location Survey Form
	Retiree Addendum Form
	Alternate Plan Agreement
	Group Cancellation Form
	Prior Deductible Credit Form

BCBSM One-Subscriber and Groups of One Enrollment Forms
	New Business Checklist for OSG & GOO
	10/01/09 BCBSM OSG Agreement
	Group Underwriting Roster
	Enrollment Change of Status Form
	Employee Waiver Form

BCN 2+ Group Enrollment Forms
	New Business Checklist for 2plus Groups
	10/01/09 BCN Job Aid
	Group Underwriting Roster
	10/01/09 BCN New Group
	10/01/09 BCN Benefit Change
	BCN HRA Addendum Final
	HRA - BSC - group agreement final with Addendum
	Enrollment Change of Status Form
	Employee Waiver Form
	Prior Deductible Credit
	Group Authorization Agreement for Automatic Payments Form

BCN One-Subscriber and Groups of One Enrollment Forms
	New Business Checklist for OSG & GOO
	10/01/09 BCN OSG
	Employee Enrollment & Change of Status Form
	Group Underwriting Roster
	Employee Waiver Form
	One Subscriber Group Checklist

AAC/BCBSM/BCN Forms
	Prescription Drug Claim Form
	Member Application for Payment Consideration
	Rate Renewal Certification Form and Job Aid
	Agent Confirmation Document
	BCBSM-BCN Agent of Record Policy
	Agent of Record Letter - Sample
	Commission Payment Designation
	BCBSM-BCN Commission Schedule
	Retiree Agreement
	VSP Out-of-Network Reimbursement Form
	Member Authorization for Automatic Payments form