Employee Enrollment Application - BCBSFL - Florida Blue 2025

1. Click ‘Get Form’ to open the Employee Enrollment Application in the editor.
2. Begin with Section A: Current Information. Fill in your Group Name, Division #, and Group #. Ensure you enter the Effective Date of Coverage and Date of Hire accurately.
3. Proceed to Section B: Employee Information. Enter your Social Security Number, Last Name, First Name, and other personal details like Street Address and Phone Number.
4. In Section C: Health Coverage Level and Plan Information, select your desired health coverage option. If applicable, provide your BlueOptions Plan # or any other relevant plan numbers.
5. Complete Section D: Vision Coverage Level by selecting your vision coverage preference. Remember to sign and date where indicated.
6. For Section E: Dependent Information, list any dependents as required. Use a separate sheet if necessary.
7. Finally, review Section F: Other Health Insurance Information for accuracy before signing in Section G to confirm acceptance of coverage.

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