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Have your employer's HR ‘epresentative sign and date the "Employer signature” section, Subscriber information: ‘+ Ifthe responsible individual isnot a U.S. citizen, check the box for non-US. citizen. Enter a taxpayer identification number inthe "Social Security/TIN number" field if the responsible individual checked the box as a non-U.S. eiizen, For a U.S. citizen, enter the nine-diit Social Security number (required for all members) ofthe responsible individual (Example 10020000) ‘© Enter new home address beginning with street address, city, state and ZIP code. Enter email address to receive health and wellness information. ‘© Enter new county name for home address and country name (if other than USA). Enter new primary phone, if changing, and indicate if home, work or cel. Enter new secondary phone number and indicate if home, work or all persons to be added or deleted. Enter name(s) on appropriate line ~Spouse, Dependent 1, 2, 3 and 4 as applicable. Complete additonal forms if all your dependents do no n. Enter a taxpayer identification number 1 nine-digit Social Security number (required Relationship codes: N- Child (by birth or adoption) ‘A- Child adoption n process ** (C- Court order coverage (QMCSO)"* SP - Spouse S- Stepchild L- Legal guardianship ** DP - Domestic partner P - Principal support (BCN only) * ‘SD Sponsored dependent * = Altach documentation “= Attach court order“ = Attach physician statement ‘© Enter the spouse's or dependent's permanent address if different from the address indicated above. Coordination of benefits information: ‘¢ Indicate "Yes" or "No and address, other your spouse or d ‘coverage applies ‘complete name of person covered, group name, policy number, carrer name Health savings, health reimbursement and flexible spending account options: © Check all applicable options. Blue Cross only: See Page 8 for four-digit product indicator code. Return to Page 2 or 6, enter the four-digit Blue Cross product indicator code and enter goal amount. Employerigroup use only: ‘© Enter employer or group name and employee reference ID or department number, if applicable. Enter benefit code (service code, package code). For the plan code fied, enter 10 to represent Blue Cross Blue Shield of Michigan. Enter date of hire and effective date * Piease check all applicable boxes to indicate coverage selected. enrolled in COBRA, check the reason for COBRA. ‘© Medicare status: Indicate if any members listed are enrolled in Medicare. If "Yes", check the reason category to explain the member's enrollment in Medicare. Indicate f Medicare is primary of if Blue Cross or BCN is primary and enter effective date of the Medicare Parts A, 8 and D coverage. Please attach a copy of the Medicare card. Page 7of9 CF a590AUG 18 Please provide all documentation required for enrollment.