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Blue Access for Producers

Downloadable Forms for 2-50 Employees


BlueAdvantage Entrepreneur/CPO


Form Name Form Number Date

Employer Enrollment
BCBSIL Submission form for Small Groups 

23640

09/11
Submission Guidelines for Small Group Health Coverage 

23162

02/11
Small Group Standard Health Application 

#22997, #23071

12/11, 01/11
HMO/CPO Provider Selection Enrollment and Change Form 

#22840

01/11
Producer/Employer Tips for Submitting New Small Groups Flier  #22018 06/09
New Business Checklist  #20910 09/12
Benefit Program Application Form  #GA-10-9-SMGRP 09/12
Addendum to the Insured BPA Regarding Affiliated Companies  #MGA-10-1-ADD 2007
Benefit Plan Selection Form 
(For Accounts Effective 1/1/13 and after)		 #GA-10-9-SMGRP BPSF 01/13
Benefit Plan Selection Form 
(For Accounts Effective 7/1/12 and after)		 #GA-10-9-SMGRP BPSF 07/12
Benefit Plan Selection Form 
(For Accounts Effective 8/1/11 and after)		 #GA-10-9-SMGRP BPSF 08/11
Standard Authorization Form and other HIPAA Privacy Forms    
Group Information Form  #20561 08/05
Small Group HCSC/FDL Disclosure Form  #EB4644 03/04
Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions  #21122.0111 01/11
Information Regarding Medicare Secondary Payer (MSP) Statute  #21091.0609 06/09
MSP Fact Sheet  

#24443.0612

06/12
Individual Medicare Secondary Payer Form  #20473 10/04
General Notice of Special Enrollment Rights and Preexisting Condition Exclusion  #22963 09/11
Affidavit of Domestic Partnership  #20551 01/05

Account Maintenance and Supply Forms
Group Administrator's Member Transactions Form  #20406 06/10
Enrollment Change Request Form  #22735 06/10
Medical Claim Form  #20479 06/07
International Claim Form  #N35-10-118  
COBRA Election Form     
COBRA Notification Form     
IL Employee Continuation Privilege Election Form  #24056 02/12
IL Continuation Group Request From  #24044 02/12
Student Certification Form  #23402.0611 06/11
Dependent Student Medical Leave Certification Form  #23077.0111 01/11
Statement of Termination of Domestic Partnership  #20560 02/07
Tax Information on Health Benefits for Domestic Partnership  #20559 02/07

Broker of Record
Broker of Record Letter  #EB5063 05/01