FL BCBS

Apply for FREE or low cost Blue Cross Blue Shield Health Insurance
Florida residents only.

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Who helped you today?
Please make sure to find out the name of the specialist helping you today.
Specialist/Technician:
Specialist/Technician Who Assisted You Today:
Specialist/Technicians Name*
First NameLast Name
Before we begin, please acknowledge that by checking this box, you agree to the following:*
About You
Your Name*
First NameMiddle NameLast Name
Phone Number*
Please enter a valid phone number.
Confirm Phone Number*
Please enter a valid phone number.
Email*

Confirmation Emailexample@example.com
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Birth Date*
MonthDayYear
Social Security Number*
Please select all that apply*
Married, Filing JointlyMarried, Filing SeparatelySmokerPregnantAmerican Indian or Alaskan NativeNone of the above apply to me
Name of Spouse
First NameMiddle NameLast Name
Spouse Birth Date
MonthDayYear
Spouse Social Security Number
Number of Dependents
Dependent #1 Full Name
First NameLast Name
Dependent #1 Birth Date
MonthDayYear
Dependent #1 Social Security Number
Dependent #2 Full Name
First NameLast Name
Dependent #2 Birth Date
MonthDayYear
Dependent #2 Social Security Number
Dependent #3 Full Name
First NameLast Name
Dependent #3 Birth Date
MonthDayYear
Dependent #3 Social Security Number
Dependent #4 Full Name
First NameLast Name
Dependent #4 Birth Date
MonthDayYear
Dependent #4 Social Security Number
Employer Information
If you are not working, but actively seeking work, please fill out the information based on if you were hired.
Employer
Frequency of Pay
DailyWeeklyBi-Weekly or Bi-MonthlyMonthlyOther
Expected 2021 Income (annual)*
How much do you anticipate earning this year? If you are not working, but seeking work, please let us know what you plan to make if hired.
Calculator (to help calculate earnings, if needed)
Identification
Please upload CLEAR pictures of government issued identification
Government Issued State ID Number *
Please take a clear photo of the front of your ID*
Please take a clear photo of the back of your ID
Acknowledgements
By signing, I verify that all of the information provided on this form is true and accurate, to the best of my knowledge, and grant you the permission to enroll me in healthcare.*
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Apply for FREE or low cost Blue Cross Blue Shield Health Insurance

Who helped you today?