Large Group Member Application - Blue Cross & Blue Shield of ... 2026

1. Click ‘Get Form’ to open the Large Group Member Application in the editor.
2. Begin with Section 1, where the plan administrator should fill in the employer information, including group name, effective date, and group number. Ensure all fields are completed clearly.
3. Move to Section 2 for employee information. Fill in personal details such as last name, first name, date of birth, and contact information. Don’t forget to indicate marital status and primary care physician details.
4. In Section 3, select your health plan options. Choose between medical and dental plans based on your needs and specify any additional products you are selecting.
5. If applicable, complete Section 4 for spouse information using the same format as Section 2. Ensure accuracy in all entries.
6. For dependent information in Section 5, list each dependent's details accurately. Attach a dependent addendum if necessary.
7. In Section 6, provide details about any other insurance coverage you or your dependents may have.
8. Finally, sign and date the application in Section 7 to certify that all provided information is accurate.

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