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Blue Shield of California
Application Instructions for California Residents |
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PLEASE BOOKMARK THIS PAGE IN YOUR
BROWSER BEFORE YOU CONTINUE
This page provides the link that enables you to download, fill in online and print your completed application to mail for Blue Shield of California's Individual and Family plans. You must be a California Resident in order to apply for coverage. You need to have Adobe Acrobat Reader (Version 5 or higher) in order to properly view, complete and print the application. If you do not have Adobe Acrobat Reader please click in the Adobe Acrobat Icon and download it  from their site. If you would prefer to use the New Blue Shield of California Online Application in place of completing the paper application click here for the online application.
Please Note: Coverage is not available if:
1. Any family member is currently pregnant (whether or not listed on the application) or in the process of adoption.
2. The applicant has not resided in the U.S. for the last six (6) consecutive months.
Coverage is not guaranteed. Your application must be approved and accepted in writing by Blue Shield of California. Do not cancel existing coverage until you receive written notification by Blue Shield.
Instructions:
- For your own protection, you, the applicant, must complete the application.
- You are solely responsible for its accuracy and completeness.
- All information must be stated accurately.
- All questions must be answered in full or the application may be returned to you and may result in a delay in processing.
- For additional information or explanations, attach additional sheets if necessary. All attachments must be signed and dated
- This application must be completed and signed in blue or black ink.
- Sign and date Part 9 of the application. Signatures are required for all applicants, including your spouse and dependents age 18 and older.
- This application must be received within 30 days from signature date.
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- Even if the application is approved, any misstatements or omissions may result in future claims being denied and the plan being voided from the beginning.
- Your insurance will become effective only if this application is approved as applied for, the appropriate premium is enclosed, and other specific conditions are met.
- Please return this application and your check to (Make Check payable to "Blue Shield of California"):
Mail all Applications for the following States to the address below: California, Arizona, Nevada, Ohio, Indiana, Illinois, Texas, Utah, Wyoming
Attention: Timothy N. Jennings
Application Processing
P O Box 6374
Jackson, WY 83002-6374
Overnight Deliveries for California Applications
Attention: Timothy N. Jennings
Application Processing
650 Lariat Loop
Jackson, WY 83001
To Expedite Processing Please Fax Application to: Fax# 415-651-8696 or apply online
Application Tips
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Provide answers to each question, even if you are not sure it applies to you. This speeds processing of your application
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A complete physical examination is no longer required for any family member age 55 and older.
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It is important that you complete "Part 7" of the application by listing all applicants in this section. Leaving it blank is no longer acceptable by Blue Shield of California. If you are not sure of dates of service please provide your best estimate.
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Indicate your billing choice at the second page of the application. (If you choose Easy$Pay, complete the Easy$Pay form included with the application.
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If married: list the younger spouse as the applicant. It may lower your monthly dues.
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Include your check or money order made payable to "Blue Shield of California"
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If you have any questions please call us at (619) 435-6700.
Billing Information
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Monthly Billing (available with Bank Draft Authorization): Submit the one (1) months premium, complete the Monthly Bank Draft Authorization (Easy$Pay) and attach a blank check marked "VOID" to this form.
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Monthly Billing received monthly bill via US Mail
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Quarterly billing: Submit the three (3)-month (quarterly) premium
You can now download the application by clinking the link below. Another window will open in your browser and bring you the application. Simply complete it online if desired and then print it from your browser or print it first and then complete by hand.
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Aetna
