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Option One Short Term Plan
Application Page
PLEASE
PRINT THIS INSTRUCTION PAGE
BEFORE YOUR CONTINUE
Download
and print the Blue Shield of California Life & Health,
(formally CPIC Life) Option One application by following
the instructions listed below. Because the application
is viewed in the Adobe PDF format you will need Adobe
Acrobat Reader 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.
The
link at the bottom of this page will down load the application
for the California Option One Short Term Health Plan.
The application will be viewed in your browser and you
will simply print it directly from your browser and
complete the application 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.
Select the mode of payment. You can either send
a check made payable to "Blue Shield Life"
or you may choose to use the MasterCard/VISA/AMEX payment
option. If you choose to make payment via the
MasterCard/VISA/AMEX Option be sure you list your card
information and sign the card authorization section.
If you have not already looked at the rates please do
so now by
clicking
here.
3.
It is very important that if you need a specific effective
date then request the date desired in the Plan Selection
potion of the application. If you do not specify
a future effective date then Blue Shield of California
Life & Health 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
Application Processing
835 D Avenue #5
Coronado, CA 92118
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# (707)778-0425.
5.
If you have any questions call us toll free at (800)
366-4713. You may also email questions to us at
sales@individualhealth.com
.
DOWNLOAD
APPLICATION NOW |
