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Option Twelve
Short Term Health Insurance Plan
For California Residents
Application Instructions
PLEASE
PRINT THIS INSTRUCTION PAGE
BEFORE YOUR CONTINUE
You
can download and print the Blue Shield of California
Life & Health (formally CPIC Life) Option Twelve
application from our website by following the instructions
listed on this page. Because the application is
in the Adobe PDF format you will need Adobe Acrobat
to download and print the application form. If
you do not have Adobe's Acrobat program click
here.
This
is a free program from Adobe.
Once
you have downloaded the program simply print it from
your browser and complete it as follows:
1.
Complete the application answering all of the questions
on both pages. Be sure to sign and date the application
when completed. Remember to complete the Beneficiary
section on the application as your plan will have an
additional benefit of $50,000 of Accidental Death and
Dismemberment Insurance. You must not leave any
questions blank.
2.
Be sure that you select the mode of payment. Make
your Check payable to "Blue Shield Life" and
return it with your completed application. If you
have not already looked at the rates please do so now
by clicking
here.
3.
Very Important: If you need a specific
effective date then request the date desired in the
Plan Selection portion of the application. If
you do not specify a future effective date then Blue
Shield Life will give an effective date of 12:01am on
the date following the postmark date stamped on the
envelope coming back to our office.
4.
Return the completed application to the following address:
Jennings
Insurance Services
Application Processing
P O Box
180761
Coronado, CA 92178
Overnight
Shipments:
Jennings
Insurance Services
Attention: Timothy Jennings
Regional Processing
650 Lariat Loop
Jackson, WY 83001
Fax
Option:
If
you wish to expidite the processing of your CPIC
Life Option One application you can fax it directly
to CPIC Life at FAX# (415) 651-8696.
5.
If you have any questions either call us toll free at
(800)366-4713 or email questions to sales@individualhealth.com
.
DOWNLOAD
APPLICATION NOW |
