Price Associates Insurance Services, Inc.
Providing Exemplary Service to Agents for Over 30 years.
Blue Cross Large Group Downloads
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Applications & Forms Form # Effective
Declaration of Domestic Partnership Affidavit - Standard  NA  01/05
Declination of Coverage Form  SM2079  01/06
Declination of Coverage Form (Spanish)  SM2107  01/06
Disabled Dependent Certification  NA  04/05
EmployeeElect Employer Group Application (51-99)  10174  03/06
EmployeeElect Enrollment (51-99)  10175  03/04
EmployeeElect Enrollment (51-99) (Spanish)  SC11210  03/04
Employer Group Application (51-250)  SC10345  09/05
Employer Group Application 250+  NA  05/05
Group Implementation Questionnaire 126+  NA  05/05
Life & Disability Forms  NA  01/06
Medical, Life & Dental Enrollment Form  GC4050  01/05
Medical, Life & Dental Enrollment Form (Spanish)  GC4053  01/05
Risk Evaluation Questionnaire 125+  NA  04/05
Termination of Domestic Partnership Form - California  NA  01/05
Termination of Domestic Partnership Form - Statutory  NA  01/05
Totally Disabled Employee/Dependent Questionnaire (Spanish)  NA  05/05
Totally Disabled Information Request  NA  05/05
Benefits & Guides Form # Effective
AB 2208 Domestic Partners Q & A  NA  12/04
Benefit Summaries December 2006  NA  12/06
Domestic Partner Comparison Chart  NA  01/05
Domestic Partnership Affidavit - California  NA  01/05
Domestic Partnership Affidavit - Statutory  NA  01/05
Summary Plan Description  NA  05/05
Transition Assistance Program  NA  12/03
COBRA Form # Effective
COBRA  GC4110  01/05
Friday, May 09 2008 
License: 0596691
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