Price Associates Insurance Services, Inc.
Providing Exemplary Service to Agents for Over 30 years.
Blue Cross Small Group Downloads
click on the to download file
Applications & Forms Form # Effective
Affidavit of Domestic Partnership  IS2327  03/05
Benefit Modification Inquiry  IS2419  04/05
BeneFits - Employee Application - Spanish  10526SP  11/04
BeneFits – Employee Application  10526  01/07
BeneFits – Employer Application  10525  09/06
Change of Coverage Application  IS2418  05/04
Chase Employee Enrollment Form  NA  03/07
Chase Employer Initiation Form  NA  03/07
Conditions of Enrollment (Seasonal Coverage)  10080  09/04
Conditions of Enrollment for Start-Up Companies  IS2416  04/06
Custodial Parent Verification Form  NA  01/06
Direct Deposit  9318  07/04
Employee Addition Application  8480  05/04
Employee Application - Spanish  IS2295  05/04
EmployeeElect Application  3345  03/07
EmployeeElect Employer Application  5773  03/07
Employer's Statement of Understanding  10722  04/07
Hippa Authorization  NA  11/05
Information Change Form  5063  04/05
Life Enrollment for Existing Employees and/or Beneficiary Designation Form  WL4004  05/06
Life Flyer  ECASH2053C  02/08
Mellon Bank HSA Agreement  NA  04/07
New Business Inquiry  IS2417  04/05
Patient Claim Form  GS-5  11/95
POP Enrollment Form  SC1380  02/05
Prescription Drug Claim Form  C0003-100-PDP  12/05
Rapid Quote Request (all Small Group plans)  12731  04/06
Request a new Dental Blue Plan  MCAFRC684B  01/08
RX Claim Forms (Mail Order)  NA  03/02
Salud-Mexico Application & Brochure  CC0194  01/08
Small Group Life Enrollment for Existing Employees  MCAFR1149CEN  03/08
SmileNet Sales Brochure & Application  11038  10/05
Sole Proprietor, Partner, or Corporate Officer Statement  ME8054  04/05
Standard Enrollment/Translator's Statement  7077  06/03
Sub-Agent Application for Appointment  IS2010  03/04
Benefits & Guides Form # Effective
1% Medical/Life Sales Slick  12357  04/07
Add value with Dental, Vision and Life  ECASH2163CEN  02/08
BeneFits You Choose  11692  03/07
Caring for the Whole You  7702  05/06
Caring for the Whole You (Spanish)  7702SP  05/06
Ceridian FSA Proposal  NA  12/02
Ceridian FSA/Flex123 Proposal  NA  12/02
Employee Choice - You Choose (Spanish)  11490SP  05/06
Employee Choice – You Choose  11490  02/07
EmployeeChoice Agent Guide  SC1553  07/05
EmployeeChoice Medical Comparison  11486  04/06
EmployeeChoice Rate Guide  11487  01/08
EmployeeChoice you Choose  11490  02/07
EmployeeElect Medical Plans  11274  04/06
EmployeeElect You Choose Brochure  ECABR1179CEN  02/08
Employer Access Quick Reference  13827  11/06
Employer Access User Manual  SC2165  02/07
Generic Drug Poster  10082  07/05
Group Administrator Manual  3357  04/07
Life Rate Sheet  MCASH1203C  03/08
Metallic Comparison Grid  BCASH0913B  02/08
Mexico Consulate Flyer  11917  11/05
mybcclink for Small Group Employers User Guide  GF0007  03/05
Small Group Supplemental Term Life Sales Slick  7324  10/04
SmileNet Sales Postcard  11040  08/05
Specialty Brochure  12049  05/07
Tech Tools for Sales Success  5420  08/04
Term Life Matrix  ECASH2164CEN  02/08
Underwriting Guidelines  IW8007  11/05
Uninsured Market Tool Kit  9819  11/04
Why Blue Cross  9627  06/04
Worker’s Comp Enrollment Guide  IS7149  07/06
You Choose Brochure - Spanish  IS5256SP  05/06
Dental Form # Effective
Basic Option PPO Dental Plan  3326  03/01
BeneFits Dental Plan Change Request Form  MCAFR2387CEN  02/08
Dental Blue Benefits  MCASH0682B  01/08
Dental Blue Gold 100  13941  10/07
Dental Blue Gold 200  13936  04/07
Dental Blue Gold 300  13937  04/07
Dental Blue Gold Plus 100  13938  10/07
Dental Blue Gold Plus 200  13939  04/07
Dental Blue Gold Plus 300  13940  04/07
Dental Blue Plan Change Request Form  MCAFR0684B  02/08
Dental Blue Platinum 100  13941  10/07
Dental Blue Platinum 200  13942  04/07
Dental Blue Platinum 300  13943  04/07
Dental Blue Platinum Plus 100  13944  10/07
Dental Blue Platinum Plus 200  13945  04/07
Dental Blue Platinum Plus 300  13946  04/07
Dental Blue Rate Sheet  MCARG0683B  02/08
Dental Blue Rates  NA  04/07
Dental Blue Silver 100  13929  10/07
Dental Blue Silver 200  13930  04/07
Dental Blue Silver 300  13931  04/07
Dental Blue Silver Plus 100  13932  10/07
Dental Blue Silver Plus 200  13933  04/07
Dental Blue Silver Plus 300  13934  04/07
Dental Blue Silver Plus 300  13934  04/07
Dental Employee Application  IS2346  05/02
Dental Plan Change Request Form  MCAFR2374CEN  02/08
Dental Rate Sheet  MCASH1201C  03/08
Dental SelectHMO Plan  3323  07/03
DentalNet Plan  3324  04/06
Gold 1500 PPO Dental Plan  8850  03/06
Gold Preferred 1500 PPO Dental Plan  8851  05/06
High Option PPO Dental Plan  3325  05/04
Metallic PPO Dental Plan Options  10150  05/06
Platinum 2000 PPO Dental Plan  8852  03/06
Platinum Preferred 2000 PPO  8853  05/06
Platinum Preferred 2000 PPO Dental Plan  8853  03/06
Saver PPO  5095  04/06
Silver 1000 PPO Dental Plan  8849  03/06
Small Group Dental Matrix  MCASH0685B  01/08
Standard Option Fee for Service (FFS) Dental Plan  3338  04/05
Standard Option PPO Dental Plan  3327  05/03
Voluntary Dental Applicaton  5990A  05/04
Voluntary Dental Plan  5991  01/06
EPO Form # Effective
High Deductible EPO  5102r  04/04
Focal Renewal 2008 Form # Effective
51-99 EmployeeElect - RAF Engine  NA  05/08
51-99 EmployeeElect - Rate Guide  BCABR1010CEN  05/08
51-99 EmployeeElect Rate Action Broker Guide  BCABR1012CEN  05/08
Add Value with Dental, Vision and Life Specialty Brochure  ECASH2163CEN  05/08
BeneFits - RAF Engine  NA  05/08
BeneFits - Rate Guide  BCABR1017CEN  05/08
BeneFits Dental Plan Change Request Form  MCAFR2387CEN  05/08
BeneFits Medical Plan Change Request Form  ECAFR1222CEN  05/08
Blue View Vision Small Group Employer Slick  ECASH1883B  05/08
CA Small Group Life Rate Sheet Insert  MCASH1203C  05/08
CA Small Group Specialty Brochure  ECABR2031C  05/08
CA Small Group Specialty Dental Rate Sheet Insert  MCASH1201C  05/08
CA Small Group Vision Rate Sheet Insert  MCASH1202C  05/08
Dental Blue Plan Change Request Form  MCASH1152CEN  05/08
Dental Blue Rate Sheet  MCARG0683B  05/08
Dental Plan Change Request Form  MCAFR2374CEN  05/08
EmployeeChoice - RAF Engine  NA  05/08
EmployeeChoice - Rate Guide  BCABR1016CEN  05/08
EmployeeChoice Medical Plan Change Request Form  ECAFR1225CEN  05/08
EmployeeElect - RAF Engine  NA  05/08
EmployeeElect - Rate Guide  BCABR1015CEN  05/08
EmployeeElect Medical Plan Change Request Form - All Plans  ECAFR1223CEN  05/08
EmployeeElect Medical Plan Change Request Form - Designated Plans  ECAFR1224CEN  05/08
EmployeeElect Plan Comparison Tool  NA  05/08
Grievance procedure Notice  MCASH1152CEN  05/08
HIPPA Notice of Privacy Practices  MCASH1150CEN  05/08
Life Change Request Form  MCAFR1149CEN  05/08
Life Flyer  ECASH2053C  05/08
Medical only - Employer Letter  ECALT1800CEN  05/08
Medical Specialty - Employer Letters  ECALT2256CEN  05/08
Metallic Comparison Grid  BCASH0913B  05/08
Rate Action Agent Guide  BCAHB1007CEN  05/08
Rate Action Presentation  NA  05/08
Small Group Term Life Insurance Matrix  ECASH2164CEN  05/08
Specialty only - Employer Letter  ECALT1795CEN  05/08
Updated Medicare Part D Credible/NonCredible Grid  ECAFR1162CEN  05/08
HIPPA Form # Effective
HIPAA/GLBA Notice of Privacy Practices  NA  11/04
HIPPA Authorization Form  NA  07/04
HMO Form # Effective
Classic HMO  8639  02/07
HMO 100%  7363  04/06
Power Select HMO  1000  04/06
Saver HMO  7362  04/06
Lumenos Health Plans Form # Effective
Lumenos Broker Toolkit Folder  SC12724  01/07
Lumenos Envelope  SC2219  12/06
Lumenos HIA Frequently Asked Questions  SC13228  10/06
Lumenos HIA Plus 3000  SC2252  03/07
Lumenos HIA Plus Sales Tri-Fold  SC12726  10/06
Lumenos HSA 1500  SC2261  03/07
Lumenos HSA 3000  SC2251  03/07
Lumenos HSA Frequently Asked Questions  SC13229  12/06
Lumenos HSA Sales Tri-Fold  SC13207  10/06
Lumenos Mellon Bank HSA  SC13282  11/06
Lumenos Preventive Care Summary  SC13408  01/07
Lumenos Sales Brochure  13879  12/06
Lumenos Web Demo Flyer  SC13210  10/06
Lumenos You Choose  13880  12/06
PPO Form # Effective
Employee Elect Basic PPO  5097  02/07
Employee Elect PPO $45 Copay GenRX Plan  14038  03/07
Power Health Fund 500  9999  04/06
Power HealthFund 750  9998  05/06
PPO $30 Copay  7360  04/06
PPO $35 Copay GenRx  10025  04/06
PPO $40 Copay  7361  04/06
PPO 2400 (HSA Compatible)  11048  04/06
PPO 3500 (HSA Compatible)  11049  04/06
Premier PPO $20 Copay  7358  04/06
Vision Form # Effective
Blue View Vision Employer Slick  ECASH1883B  02/08
BlueView Plan Summary of Features  11343  07/05
BlueView Plan Summary of Features (Spanish)  11343SP  07/05
BlueView Plus Plan Summary of Features  11342  07/05
BlueView Plus Summary of Features (Spanish)  11342SP  07/05
BlueView Vision Sales Brochure  11272  07/05
Vision Rate Sheet  MCASH1202C  03/08
Friday, May 09 2008 
License: 0596691
© 2008 Price Associates Insurance Services, Inc.