Blue Shield 51-299 Forms
	BS 51+ Dental Master Group Application For Groups with no BS Medical Coverage (2-299 ees), 2 Pages (Rev. 04/06)
	BS 51+ Employee Application Must be completed by each enrolling employee., 6 Pages (Rev. 07/07)
	BS 51+ Employer Questionnaire For Groups 51- 299. Submit with Master Group Application, 1 Page (Rev. 3/04)
	BS 51+ Group Master Application For Groups 51-299, 6 Pages (Rev. 07/07)
	BS Affidavit of Domestic Partnership 1 Page (Rev. 1/05)
	BS Disability Addendum Provides carrier & subscriber name for DI employees. Submit with the Group Application., 1 Page (Rev. 1/04)
	BS Full Time Student Certification Submit per overage full time dependent enrolled on plan., 1 Page (Rev. 10/03)
	BS PHI Disclosure Authorization Must be signed by the plan member to authorize Blue Shield to release personal & health information to a third party., 3 Pages
	BS Refusal of Personal Coverage For member, spouse, or dependents refusing medical or dental coverage, 1 Page (Rev. 6/02)
	COBRA Group Continuation Form (HMO) For HMO COBRA enrollees, 1 Page (Rev. 2/04)
	COBRA Group Continuation Form (PPO) PPO COBRA enrollees, 2 Pages (Rev. 1/04)
	COBRAServ Waiver For groups choosing to not use Ceridian COBRA Services for COBRA administration., 1 Page (Rev. 5/07)

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For additional information, please contact Claremont at 800.696.4543 or info@claremontcompanies.com