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Supplement to Individual Enrollment Application
This form provides additional space, if needed, to list applicants and information for medical
and/or term life insurance coverage.
Primary Applicant’s Social Security or ID No.
Applicants for Coverage
FamilyElect
Please list ALL applicants (youngest to oldest) applying for coverage.
3A. For HMO Use Only
If a family member’s last name is different than yours, please explain:
Coverage
ACCURATE
Primary Care
Relation
Social Security
Last Name
Birthdate Age Height Weight
Physician
BC Life & Health Term Life Insurance
TERM LIFE COVERAGE
Applicants and/or any dependents that are approved for Level I and Level I+20 coverage will also qualify for BC Life & Health
Insurance Term Coverage at an additional charge. Applicants under the age of one year are not eligible for life insurance.
DO NOT SUBMIT PREMIUM FOR LIFE INSURANCE.
✓ Amount of Coverage
Family Member Name
Beneficiary Name
Relationship
Beneficiary Address
$15,000 $30,000 $50,000
City / State / ZIP Code
Last Doctor Visit (for any reason including checkup) – Provide information for ALL family members you wish to cover.
Name, Phone No. & Fax No. (Fax # optional)
Family Member
Reason for Visit
Abnormal Findings
of Physician or Hospital
(Explain)
Complete Address / City / State / Zip Code
Name: ______________________________
Phone: ____________ Fax: ____________
Address: ____________________________
City________________ State ____ Zip __
Name: ______________________________
Phone: ____________ Fax: ____________
Address: ____________________________
City________________ State ____ Zip __
Name: ______________________________
Phone: ____________ Fax: ____________
Address: ____________________________
City________________ State ____ Zip __
Name: ______________________________
Phone: ____________ Fax: ____________
Address: ____________________________
City________________ State ____ Zip __
Applicant’s Social Security or ID No.
Prescription Medications – List all medications taken within the last 12 months by any family member listed on this application.
Medication/Dosage/Frequency
Illness for
Family Member
which Medication
Prescribed Discontinued
Name, Phone No.
is Prescribed
of Physician or Hospital
Name: ______________________
Phone: ____________________
Name: ______________________
Phone: ____________________
Name: ______________________
Phone: ____________________
Professional Services
Give COMPLETE details in all sections below of any “Yes” answers to the questions in Section 6A.
Question # Name of Family Member (As identified on Physician’s Record) Name of Hospital, Clinic and/or Person Providing Care Phone No.
Date of Onset/Treatment (Month/Year) Treatment Rendered (i.e., X-ray, lab, surgical procedure, etc.) / Results
Question # Name of Family Member (As identified on Physician’s Record) Name of Hospital, Clinic and/or Person Providing Care Phone No.
Date of Onset/Treatment (Month/Year) Treatment Rendered (i.e., X-ray, lab, surgical procedure, etc.) / Results
Question # Name of Family Member (As identified on Physician’s Record) Name of Hospital, Clinic and/or Person Providing Care Phone No.
Date of Onset/Treatment (Month/Year) Treatment Rendered (i.e., X-ray, lab, surgical procedure, etc.) / Results
Question # Name of Family Member (As identified on Physician’s Record) Name of Hospital, Clinic and/or Person Providing Care Phone No.
Date of Onset/Treatment (Month/Year) Treatment Rendered (i.e., X-ray, lab, surgical procedure, etc.) / Results
Signatures (Required) – IMPORTANT: All applicants over age 18 must sign and date.
Today’s Date Applicant’s Dependent age 18 or over Today’s Date Applicant’s Dependent age 18 or over Blue Cross of California and BC Life & Health Insurance Company are Independent Licensees of theBlue Cross Association (BCA). The Blue Cross name and symbol are registered service marks of the BCA.

Source: http://www.paulshnable.com/ABC_IFPappSupplement_1003.pdf