EMPLOYER ENROLLMENT/CHANGE GUIDES, MEDICAL GUIDE QUESTIONNAIRE
Employer groups and/or producers can use our combination Member Enrollment/Change Guide to enroll new members for coverage or change the status of a member. This guide includes legally required notices that must be received by the enrolling member before he or she completes the enrollment form. As a group leader and/or producer, you are responsibile for ensuring the enrolling member receives these notices.

PLEASE NOTE: The enrollment guide is for use only by employer groups and/or producers. Only enrollment forms received from group leaders and/or producers will be processed. No enrollment forms my be submitted directly by any individual member to Blue Cross and Blue Shield of Louisiana – HMO Louisiana, Inc. – Southern National Life Insurance Company, Inc. or Employee’s Choice Voluntary Plans.**

NEW GROUP SALES SPREADSHEET
Group Sales Enrollment Spreadsheet [01MK6329 11/17]

REQUEST FOR PROPOSALS (RFP)
Request for Proposal [01MK4904 R10/17]

GROUP ENROLLMENT FORMS
2019 Application for Group Coverage [01MK5337 R0119]
2019 Employee Enrollment Change Form (fillable) [01MK5336 R0119] (F)
Group Enrollment Checklist

OTHER COMMONLY USED EMPLOYER FORMS
Appointment of Representative to Submit Electronic Documents and Signature for Insurance Coverage [01MK1745 R0116] (F)
Agency Fee Form [01MK6648 R0817] (F)
Authorized Delegate Form (F)
Beneficiary Designation Form – SNL [28XX1568 11/15] (F)
Continuation of Group Coverage – Blue Cross [23XX0500 R0518] (F)
Coverage Cancellation Form [23XX3160 R12/17] (F)
Coverage Cancellation Form (Spanish version) [23XX3160S R12/17]
Dental Appeal Request Form [01MK5449 09/13] — New Blue Dental effective 1/1/2014
Dependent Certification Form [24XX0205 R03/17]
First Month Premium Attestation Form
Federal Requirement for Employee Determination [01MK4926 R07/16]
Small Employer Exception [01MK4801 0117]
Group Leader Authorized Representative [01MK2807 1106]* (F)
MSP Federal Tax ID and Group Size Information Sheet [01MK4386 R01/17] (F)
Primary Care Physican (PCP) Selection [01100 01285 0117R]
Prior Carrier Health Coverage Form [23XX1938 R01/16]
Producer of Record Change Request Letter [01MK1940 R0917] (F)
Rescind Request Form [01MK6565 R0917]
Short-Term Disability Form [23XX1034 R06/05]
Twelve Month Rate Guarantee Waiver [01MK3538 R0217] (F)
Group Contact Information Update Form