Apply for coverage from Premera
BlueCross
Home | Premera
BlueCross Enrollment Form
• Standard Health Questionnaire for use with coverage that begins on or after June 10, 2010 .
Application Process and Forms
To apply for any of the Premera BlueCross individual
medical plans, please complete the following steps:
- Fill out the Application (one per
family)
Download the Premera BlueCross
Individual/Family Enrollment Application from the link above. Print the
application and fill it out completely.
- Fill out the Questionnaire (one
for each person to be covered)
Download the Standard Health
Questionnaire for Washington State. Print and complete
the questionnaire for each person
to be covered on the plan. Please refer to Completing
the Health Questionnaire to determine
if this applies.
- Provide Proof of Washington State Residency
To be eligible to purchase this plan you must be a
Washington state resident.
A photocopy of one of the following must accompany
your application to prove residency:
- Valid Washington State Driver's License or Identification
Card
- Washington State Voter Registration Card
- Current Utility Bill in your name, including
address
- Provide Certificate of Creditable Coverage
(if available)
Please refer to Credit
for Prior Coverage & HIPAA Eligibility
for more information. Please note, if you do not have
your Certificate of Creditable Coverage at the time
of application, please submit your application anyway.
Credit for pre-existing condition waiting periods
will be credited upon receipt of your Certificate
of Creditable Coverage by Premera BlueCross.
- Do not Send a Payment
Please do not send a rate payment with your application.
You will receive a statement from Premera BlueCross
upon acceptance of your application.
- Send all Enrollment Materials to:
CDA Insurance Services
P.O. Box 26540
Eugene, OR 97402
Please note: Premera BlueCross requires
all COMPLETED enrollment materials to
be postmarked to their office on or before the 20th of
the month. Incomplete enrollments may cause delays in
the effective date of your coverage. Please refer to the
checklist on the application to avoid delays.
For Example: If you wanted your medical
insurance coverage to begin on April 1, you would need
to send all of the required, completed enrollment material
to Premera BlueCross postmarked on or before March 20.
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