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
	Prior Deductible Credit Form
	4/01/08 Community Blue and Healthy Blue Living Benefit Change
	4/1/08 Flexible Blue Benefit Change Form C
	4/1/08 Ancillary Benefit Change
	4/1/08 Community Blue Enrollment & Coverage Agreements Parts A-C
	4/1/08 Flexible Blue Group Enrollment & Coverage Agreements Parts A-C
	Job Aid
	10/1/08 Ancillary Benefit Change
	10/1/08 Community Blue New Group Agreement
	10/1/08 Community Blue Benefit Change
	10/1/08 Flex Blue New Group Agreement
	10/1/08 Flex Blue Benefit Change
	10/1/08 BCBSM Job Aid
	Group Underwriting Roster
	Enrollment & Change of Status Form
	Employee Waiver Form
	Multiple Location Survey Form
	Retiree Addendum Form
	Alternate Plan Agreement
	Group Checklist 2+ Groups
BCBSM One-Subscriber and Groups of One Enrollment Forms
	10/1/07 One Subscriber Group Coverage Agreement (form did not change)
	Group Underwriting Roster
	Enrollment Change of Status Form
	Employee Waiver Form
	Group Checklist One Sub
BCN 2+ Group Enrollment Forms
	Prior Deductible Credit
	4/1/08 BCN Group Enrollment & Coverage Agreements Part A-C
	4/1/08 Ancillary Benefit Change
	4/1/08 BCN GWC Form (Part C)
	10/1/08 BCN New Group Agreement
	10/1/08 BCN Benefit Change
	10/1/08 BCN Job Aid
	Group Underwriting Roster
	Enrollment Change of Status Form
	Employee Waiver Form
	Group Checklist 2+ Groups
	Job Aid
BCN One-Subscriber and Groups of One Enrollment Forms
	One Subscriber Group Form
	Employee Enrollment & Change of Status Form
	Group Underwriting Roster
	Employee Waiver Form
	One Subscriber Group Checklist
AAC/BCBSM Forms
	Prescription Drug Claim Form
	Member Application for Payment Consideration
	Rate Renewal Certification Form
	Agent Confirmation Document
	BCBSM-BCN Agent of Record Policy
	Agent of Record Letter - Sample
	Commission Payment Designation
	BCBSM-BCN Commission Schedule
	Retiree Agreement
Companion Life
	Agent Licensing Agreement
	Companion New Business Checklist
	Employee Application
	Health Statement
	Employer 2-9 Group Life & STD Brochure & Application
	2-9 Group LTD Brochure
	Employer 2-9 Group LTD Application
	10+ Group & Voluntary Employer Application
	Voluntary LTD Brochure
	Voluntary STD Brochure
	Voluntary STD Employee Application
	Voluntary Dental Employer Application
	Voluntary Dental Rates & Brochure
	Voluntary Life Brochure
	Voluntary Life Employer Application
	Voluntary Vision by Design Brochure
	Voluntary Vision by Design Discount Plan
	Voluntary Vision by Design Employer Application
Medicare Drug Subsidy Kit
	Retiree Drug Subsidy Support Kit-Group
	Guidance for Agents on Retiree Drug Subsidy Support