For on-exchange policies, please visit your carrier's website:
Blue Cross Blue Shield of Illinois
For off-exchange policies, please view your carrier's application agreement below:
Blue Cross Blue Shield of Illinois Application Agreement
ACKNOWLEDGMENTS
The Applicant, to the best of his/her knowledge and belief, represents and agrees as follows:
This Application is not coverage. Medical Expense Coverage will not begin until the effective date of the policy and the first month’s premium is paid.
If I use an agent or broker, they cannot accept risks or modify policies or requirements of BCBSIL.
My premium, and that of my spouse and/or dependent(s), if any, will be calculated in accordance with applicable law and regulations.
I understand that if any person, on my behalf or on behalf of my spouse or other dependents, knowingly presents a fraudulent claim for payment of a loss or benefit or fraudulently misstates a material fact on this Application, coverage may be rescinded. A rescission of coverage is a cancellation or discontinuance of coverage that has a retroactive effect, canceling the coverage back to the first day it became effective. I understand that I will be provided with at least 30 days advance written notice before my coverage, or that of my spouse or other dependents, is rescinded.
If an Agent, Producer or Broker was working with me to purchase an Individual Policy, then BCBSIL may pay the broker a commission and/or other compensation. I understand that if I want additional information about any commissions or other compensation paid the agent or broker I should contact the agent or broker.
Agreement: I understand that any statements and answers on this Application are representations. To the best of my knowledge and belief they are true and complete. These representations constitute the basis of my Application. I understand that coverage will be effective following payment in full of the first month’s premium. The undersigned Applicant and broker acknowledge that the Applicant has read the completed Application and understands the Application which will become a part of the contract between BCBSIL and the Applicant. To the best of my information, knowledge and belief the statements and answers on this Application are true, accurate and complete.
Authorization: I authorize any medical professional, hospital, clinic or other medical or medically related facility, governmental agency, pharmacy benefit manager, retail pharmacy, pharmacy clearinghouse or other person or firm, to disclose to BCBSIL or their authorized representative, information, including copies of records, concerning advice, care or treatment provided to me and/or my dependents, including and without limitation, information relating to the prescription and use of drugs or alcohol. I also authorize the release of information relating to mental illness. In addition, I authorize BCBSIL to review and research its own records for information. I understand that BCBSIL will only disclose collected information as needed to medical entities related to my care.
I understand information obtained with my authorization may be re-disclosed by BCBSIL as permitted or required by law. If such a disclosure is required, the person or agency receiving the information will become responsible for its protection.
This Authorization is valid for two years from today, or until I terminate coverage. I understand that I have the right to revoke the Authorization at any time, in writing, by contacting BCBSIL. I further understand that I or any authorized representative will receive a copy of this authorization upon request. Any revocation will not affect the activities of BCBSIL prior to the date such revocation is received by BCBSIL.
Signatures: I acknowledge receipt of the required Schedule of Benefits and I agree that this Individual Plan is intended to be paid as my personal expense and that this Plan is offered on my representation that only I, a family member, or permissible third party as outlined in the Application will pay BCBSIL directly. I understand that BCBSIL does not accept payments of premium or cost-sharing payments directly from third parties except from those identified in Section D (family members, Required Entities, certain private non-profit foundations). I understand that a violation of these terms may result in premium and cost-sharing payments paid by a third party not being credited to my account or coverage or being refunded to me, which may result in the cancellation of my coverage for nonpayment of premium.
Special Enrollment Period Attestation and Acknowledgment: I understand that if I am applying for coverage outside of Open Enrollment, I must qualify for a Special Enrollment Period (“SEP”). I understand that in order to qualify for a SEP I must have experienced a qualifying event during the last 60 days, and I must provide acceptable proof of any qualifying event(s) with this Application in order for BCBSIL to verify my eligibility.
I represent that the proof I am providing is valid and I understand that failure to provide proof of a qualifying event will delay or prevent the processing of my Application and enrollment in coverage.
In addition I acknowledge that this coverage is intended to be individual coverage and nothing in this document creates a group health plan as defined under state and federal laws.
Warning: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.