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Blue Cross of California
Download Application Request
for Domestic Coverage
  
 
Blue Cross of California provides new applicants with two options to apply for insurance. One is a state of the art web based application program from which you can apply for Individual and Family coverages. The second option is to complete a paper application and submit it via FAX or US Mail. As with all new technologies there can be gliches. Below is a brief form we ask that you complete before you are directed to the Downloadable Application. This information is used assist you with the application process. Should you experience technical issues we want to help you address them in a timely fashion so your application is not delayed. Most of the time the application experience is a simple and pleasant one. If you would prefer applying online via the internet rather than completing the paper version of the application click here.
 
Preferred Method of Contact:

Referral Source:
Name:
Zip:
Email Address:
Please Note: If you would like us to mail you an enrollment kit which includes plan descriptions, rates and application materials please indicate so by selecting "YES" from the box below and then provide your mailing address information. We will mail you the complete enrollment kit from Blue Cross of California. If you do not want the enrollment kit mailed and you prefer to download the information please select "NO".
Enrollment Kit:
Mailing Address:
City:
State:
Zip Code:
Day Phone:
Evening Phone:
Family Members Applying: Applicant
 Age:
Spouse Age:
Child1 Age:
Child2 Age:
Child3 Age:
Comments:

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