For your own
protection, you, the applicant,
must complete the application. You
are solely responsible for its accuracy
All information must be stated
All questions must be answered
in full or the application may be
returned to you and may result in
a delay in processing.
For additional information or explanations,
attach additional sheets if necessary.
All attachments must be signed and
This application must be completed
and signed in blue or black ink.
Sign and date Part 8 of the application.
Signatures are required for all
applicants, including your spouse
and dependents age 18 and older.
This application must be received
within 30 days from signature date.
Even if the application is approved,
any misstatements or omissions may
result in future claims being denied
and the plan being voided from the
Your insurance will become effective
only if this application is approved
as applied for, the appropriate
premium is enclosed, and other specific
conditions are met.
Please return this application
and your check to Make Check payable
to "Blue Cross of California"
or " Blue Shield of California")
Include your check or money order
made payable to "Blue Cross
of California" , " Blue
Shield of California" .
If you have any questions please
call us at (818) 987-5000