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UNGROUP PLAN CHANGE REQUEST FORM FOR 2017 EFFECTIVE DATES(Please Print)Mail to: Horizon BCBS NJ Attn: Consumer Enrollment Dept. P.O. Box 1330 Newark, NJ 071011330 Email to: individualapplication@HorizonBlue.com

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How to fill out non-group plan change request

01

Obtain a non-group plan change request form from your insurance provider.

02

Fill out all required personal information such as name, address, and policy number.

03

Indicate the reason for the plan change request and provide any supporting documentation if necessary.

04

Review the form to ensure all information is accurate and complete.

05

Submit the completed form to your insurance provider either by mail, fax, or online.

Who needs non-group plan change request?

01

Individuals who are currently enrolled in a non-group insurance plan and wish to make changes to their coverage.

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What is non-group plan change request?

Non-group plan change request is a form submitted by an individual to request changes to their current insurance plan outside of the open enrollment period.

Who is required to file non-group plan change request?

Any individual who wants to make changes to their insurance plan outside of the open enrollment period is required to file a non-group plan change request.

How to fill out non-group plan change request?

To fill out a non-group plan change request, individuals must provide their personal information, current insurance plan details, desired changes, and any supporting documentation.

What is the purpose of non-group plan change request?

The purpose of a non-group plan change request is to allow individuals to make necessary changes to their insurance plan outside of the open enrollment period.

What information must be reported on non-group plan change request?

Information such as personal details, current insurance plan information, desired changes, and any supporting documentation must be reported on a non-group plan change request.

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