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This document is designed for individuals seeking to enroll in health insurance plans offered by Blue Cross of California and BC Life & Health Insurance Company.
We are not affiliated with any brand or entity on this form
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How to fill out individual enrollment application

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How to fill out Individual Enrollment Application

01
Obtain the Individual Enrollment Application form from the appropriate organization or their website.
02
Fill out your personal information, including your name, address, date of birth, and contact information.
03
Specify the type of coverage or program you are applying for.
04
Provide any required documentation, such as proof of identity or residence.
05
Complete any additional sections that apply to your specific situation.
06
Review your application for accuracy and completeness.
07
Sign and date the application.
08
Submit the application as instructed, either by mail or electronically.

Who needs Individual Enrollment Application?

01
Individuals seeking health insurance coverage.
02
People applying for government assistance programs.
03
New applicants for a specific enrollment period.
04
Individuals transitioning between plans or coverage types.
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There are 3 easy ways to take the next step. Shop and enroll online. Just click the “Enroll Now” button and you're on your way. Give us a call. We're here to help from 8 a.m. to 8 p.m., 7 days a week. Get more information. If you're not quite ready to shop and enroll, you can fill out the form to get more information.
This form is used for proof of group health care coverage based on current employment. This information is needed to process your Medicare enrollment application.
You can apply online or you can mail your completed CMS 40B, Application for Enrollment in Medicare - Part B (Medical Insurance) to your local Social Security office.
Fill out the Application for Enrollment in Medicare Part B (CMS-40B) (PDF). If you are applying during the Special Enrollment Period, also fill out the Request for Employment Information (CMS-L564) (PDF).
You can only sign up for Part B at certain times. Learn about Part A & Part B sign up periods. Fill out form CMS-40B. Send the completed form to your local Social Security office by fax or mail.

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The Individual Enrollment Application is a form used to enroll individuals in specific programs or services, typically related to healthcare or insurance.
Individuals seeking to enroll in certain health plans or insurance coverage are typically required to file the Individual Enrollment Application.
To fill out the Individual Enrollment Application, individuals need to provide personal information, including their name, address, date of birth, and details about the insurance plan they wish to enroll in.
The purpose of the Individual Enrollment Application is to gather necessary information to process an individual's enrollment into a program or insurance plan.
The information that must be reported on the Individual Enrollment Application includes personal identification details, contact information, eligibility information, and specific plan selection.
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