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Benefit Brokerage Services offers the convenience of access to forms and applications of the following carriers: AIG/MES Blue Cross Blue Cross Careousel Blue Shield Fort Dearborn HealthNet Landmark MetLife

AIG/MES

Forms for Download

Employer Group Sold Case Form

Employee Enrollment Form

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Blue Cross

Forms for Download

2-50 Small Group Employer Application Form

2-50 Small Group Employee Application Form

2-50 Small Group Employee Chinese Application Form (Call Representative)

2-50 Small Group Employee Spanish Application Form

2-50 Existing Small Group Employee Addition Form

Small Group Change Of Coverage Application (Existing Enrollment Only)

Affidavit Of Domestic Partner

HIPAA Broker Form

Medical Claim Form

RX Claim Form (Call Representative)

Small Group Employee Information Change Form

Sole Proprietor Or Partners Statement Form

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Blue Cross Care-ousel

Forms for Download

Employer Application Form

Initial Premium Worksheet

Employee Application/Change Form

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Blue Shield

Forms for Download

Employer Application

Employee Application

Employee Change

Refusal of Coverage

Sole Proprietor, Partner, or Corporate Officer Statement

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Fort Dearborn

Forms for Download

Employee Enrollment Form

Employer Enrollment Application; 2 - 9

Employer Enrollment Application; 10 +

LTD Application Form

Death Claim Form

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HealthNet

Forms for Download

Employer Group Application Form (Call Representative)

Employee Enrollment Form

HealthNet Medical Claim Form

Health Questionnaire

Over Age Dependant Form

Affidavit Of Domestic Partnership Form

HIPPA Authorization Form (Broker)

Rx Prescription Claim Form

Medical Claim Form

Employer Dental Group Application

Employee Dental Application

Employee Dental Waiver Form

Dental Claim Form

HIPPA Dental Authorization To Disclose Medical Information

Employer Vision Group Application

Employee Vision Application

Employee Vision Waiver Form

Vision Claim Form

HIPPA Vision Authorization To Disclose Medical Information

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Landmark

Forms for Download

Employer Enrollment Application

Employee Enrollment Application

Employee Change/Termination Form

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MetLife

Forms for Download

Employer Life & Dental Sold Case Application

Employer Life & Dental Request For Participation

Employer Life & Dental Application For Group Insurance

Employee Enrollment Life Application

Employee Enrollment Dental Application

Employee Life & Dental Census Form

Employee Life & Dental Census Enrollment-Payroll Deduction Authorization

Life Beneficiary Designation

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