RESOURCE CENTER

Client Service Forms
email download
Paperwork Submission Deadlines for 2014 Effective Dates
Alert 656 has been updated to include SHOP paperwork requirements. Groups, new & existing, electing CBC SHOP products must submit all paperwork to CBC by the 15th of the month prior to effective date. There will not be an extension on this deadline.
email download
Certification of Group Size
The Certification of Group Size form should be used when a group’s enrollment does not match their true group size for rating purposes. CBC reserves the right to void any prior quotes if the group size crosses over/under 50 employees.
email download
Certification of Group Eligibility to Combine
This form is required to be completed with corporate tax docs for each entity anytime more than one company qualifies to combine. The form needs to be included with the final paperwork submitted to CBC sales.
email download
10.30.2012
Employee Enrollment-Change form (for EXISTING group)
Enrollment form to be completed by employee, for a EXISTING group with new hire/life event or existing member changing dependent coverage. This form cannot be used for new business or PPO 1-2-3 plans. *released 8/2012
email download
10.30.2012
Employee Enrollment form (for PPO 1-2-3 plans)
Enrollment form to be completed by employee, for a PPO 1-2-3 plan submission. This form cannot be used for existing group or new business. *released 8/2012
email download
10.30.2012
Application for 2-50 Group Benefits
Enrollment form to be completed by employer with 2-50 eligible employees, for new or renewal. Contains verbiage for CAAC. *released 8/2012
email download
09.24.2012
MLR Questionnaire
Required for new business beginning with 11/1/12 effective dates. This form helps CBC obtain required information important to determining future MLR rebate status.
email download
09.21.2012
Blue Cross Dental-Vision Enrollment Form (released 8/2012)
Enrollment form to be completed by employer, when adding members to a Blue Cross Dental or Blue Cross Vision plan.
email download
05.21.2012
Value Based Benefits - Setup Form
CBC launched Value Based Benefits on 7/2012 for large groups with 100+ employees. Employers can choose from 6 health incentive programs. The form is required to setup a group with the program.
email download
04.27.2011
HIPPA Disclosure form
CBC branded form to be completed by the member in order for PHI to be disclosed to a 3rd party
Email Document

Email sent successfully!

close
Email Document