BCBS Group - Midwest Insurance Brokerage Services Inc

Answer the following questions to determine if your group is eligible.

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Todays Date*
MM slash DD slash YYYY
Requested Effective Date*
MM slash DD slash YYYY
Business Information (REQUIRED)
Business Name*
Partnership*
- Yes
- No
Business Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Business County*
Business Phone Number*
Average Number of (Non-Owner) W2 Employees in Prior Calendar*

*do not count owners as employees
Total Number of Full-time Eligibe Employees*

(include ALL FT/PT/Union/Seasonal)
Total Number of Enrolling Employees*
Business Startup Date*
MM slash DD slash YYYY
Nature of Business or SIC Code*

Enrollee	First Name	Last Name	DOB (mm/dd/yyyy)	Gender	Tier Choice	Home Zip Code	State	Owner

Business Information (REQUIRED)