Establishing secure connection…Loading editor…Preparing document…

Premera Enrollment Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Other Coverage Questionnaire Enrollment

Customer Service: 800-722-1471    Hearing Impaired: 800-842-5357

An Independent Licensee of the Blue Cross Blue Shield Association

Dear Subscriber:

We appreciate your assistance in providing information about other health coverage you may have — thank you for your cooperation!

Please either review this form and call Customer Service at 1-800-722-1471 with the information or complete the form and mail to the address above.

Subscriber Name and Address

Date

Member ID

Group Number

Group Name

If you or your dependents have other health coverage, the information requested below will enable us to coordinate payment of your claim(s) with your other carrier(s). Please refer to the back of this form for answers to the most often asked coordination of benefits questions. If you require assistance in completing this form, please contact your employer or our Customer Service Department.

OTHER INSURANCE INFORMATION

Do you or any family members have any of the following:

1. Coverage with us (other than listed above)?

Subscriber Name

Date of Birth

Subscriber ID Number

Group Number

2. Medicare coverage

Name of Family Member with Medicare Coverage

Medicare ID Number

Part A Eff. Date

Part B Eff. Date

Part D Eff. Date

Retirement Date

Are you entitled to Medicare due to one of the following:

Date of Entitlement

First Dialysis Treatment

Kidney Transplant

Are you entitled to Medicare for more than one reason? If so, give the reasons for your dual entitlement.

3. Other medical, dental, prescription drug, or vision coverage?

If Yes, please complete the following sections. If more than one policy, please attach additional paper.

IF ANOTHER HEALTH INSURANCE PLAN PAYS FIRST, SEND US A COPY OF THEIR EXPLANATION OF BENEFITS.

OTHER INSURANCE COMPANY:

Company Name

Street Address

City

State

Zip Code

Telephone Number

Effective Date of Coverage

Name of Policyholder

Date of Birth

Relationship to Our Subscriber

Is policy a group coverage?

Is this COBRA coverage?

Is coverage an individual policy?

Policy ID # (Social Security #, Member #, etc.)

Group #

Employer

Are you retired?

Above policy is for:

Above policy covers:

4. If parents are divorced or legally separated, the following information is needed to determine which coverage will process claims first for dependent children.

CHILD'S NAME

FIRST

LAST

NAME OF PERSON WITH CUSTODY

RELATIONSHIP TO CHILD LISTED

NAME OF PERSON WITH FINANCIAL RESPONSIBILITY FOR HEALTH COVERAGE ACCORDING TO DIVORCE DECREE

RELATIONSHIP TO CHILD

NAME OF OTHER COVERAGE PROVIDED

* If this is different from the Other Insurance Company listed in Question Number 3, please list all other coverage information (e.g., telephone number, name of policyholder, ID Number, Group Number, etc.) on a separate sheet.

It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

SIGNATURE OF SUBSCRIBER OR SPOUSE

X

Questions and Answers to Help You Understand Coordination of Benefits (COB)

What is Coordination of Benefits (COB)?

COB is two or more health care companies working together to share the cost of health care expenses.

Why do we coordinate benefits?

Insurance regulations allow health care companies to coordinate benefits. These regulations allow us to keep your cost of health care coverage as low as possible by avoiding payment of more than the total charge of bills submitted. These rules identify one plan as “primary” (the company that pays first) and the other plan as “secondary” (the company that pays second.)

Who do I submit my bill(s) to first?

♦ If the patient is our Subscriber, submit to us first and the other plan second.

♦ If the patient is the spouse of our Subscriber, submit to the other plan first and to us second.

♦ If the patient is a dependent child, submit to the plan of the parent whose birthday falls earliest in the year. Example: mother’s birth date is May 5th and father’s birth date is November 9, submit to the mother’s plan first.

♦ If the parents of the patient are divorced or legally separated, submit first to the plan of the parent with financial responsibility for health care coverage according to the divorce decree. If not stated in the divorce decree, submit bill(s) in the following order:

A. To the plan of the parent with custody;

B. To the plan of the spouse of the parent with custody;

C. To the plan of the natural parent without custody; or

D. To the plan of the spouse of the parent without custody.

♦ If you have two coverages with us, submit each bill with both Subscriber and Group identification numbers.

♦ If Medicare is your primary carrier, submit your bill(s) to us with a copy of the Medicare Explanation of Benefits.

♦ If you are the Subscriber of more than one health care coverage, the coverage which has been effective the longest is primary. Submit your bill(s) to that carrier first.

♦ Retiree Plans may require any non-retiree coverage to be primary.

How do we coordinate benefits?

♦ When we receive your bill(s), we determine which health care company will process your bill(s) first.

♦ If you submit your bill(s) with a copy of your other health care company’s denial or an Explanation of Benefits, we will use this information to process your bill(s) promptly.

♦ If we do not receive this information with your bill(s), we contact your other health care company to obtain the information needed to process your bill(s). We always call those companies that coordinate over the telephone. This enables us to process your bill(s) promptly.

When do I receive an “Other Coverage Questionnaire”?

♦ When we have conflicting, incomplete or outdated information, you will receive a questionnaire.

♦ When your other coverage cancels, we need new coverage information.

IMPORTANT REMINDERS

♦ When we request COB information, please return the form by the date indicated to assure prompt processing of your bill(s).

♦ Always keep your health care providers (doctor, dentist, etc.) updated with your correct health care coverage information.

Enter text✕
Prepare your document for signing right on this page
  • 01 Edit the text and complete the fields
  • 02 Click Sign Now and on the next screen add recipients and signature fields in SignNow
  • 03 Start your free trial to sign and send your doc
Sign Now

What the Premera Enrollment Form Is and when it's used

The Premera Enrollment Form is the carrier-specific application used to enroll individuals and dependents in Premera health plans, including medical, dental, and vision coverage. It collects identifying and eligibility information, plan selections, dependent details, prior coverage disclosures, and signature authorization. Employers, brokers, and individual applicants use this form to start coverage, add or remove dependents, or make plan changes during qualifying events or open enrollment. Because the form contains protected health information and financial data, accuracy and secure handling matter for benefits administration, claims processing, and regulatory compliance.

Why accurate completion of a Premera Enrollment Form matters

A correctly completed enrollment form ensures timely coverage activation, correct premium allocation, and accurate claims processing while reducing administrative follow-up and coverage gaps.

Why accurate completion of a Premera Enrollment Form matters

Who typically completes and reviews these forms

Enrollment forms are completed by members, HR or benefits administrators, and brokers; carriers and payroll teams then verify and process the submission.

  • Individual employees or members who select coverage or add dependents during open enrollment or after qualifying events.
  • Employer HR or benefits staff who collect forms, verify eligibility, and transmit data to Premera.
  • Brokers and benefits consultants who assist applicants and coordinate employer-group enrollments with the carrier.

Organizations should assign a clear reviewer to confirm eligibility, dependent documentation, and signature validity before sending to the carrier.

Step-by-step: completing and submitting the form

Follow these core steps in order to complete enrollment and minimize carrier follow-up.

  • 01
    Gather documents: Collect IDs, dependent birth certificates, and proof of prior coverage where required.
  • 02
    Fill fields: Complete all required fields, using MM/DD/YYYY dates and full legal names.
  • 03
    Sign and date: Apply signatures and dates; confirm signer authority for employer-submitted forms.
  • 04
    Submit to carrier: Send via the carrier's preferred channel (broker portal, secure upload, or HRIS) and retain a copy.

Typical processing flow after you submit the form

A standard processing chain helps you track status: verification, enrollee notification, premium set-up, and coverage activation.

  • Receipt & intake: Carrier or broker acknowledges the form and logs the submission.
  • Eligibility check: Verifier confirms dependent eligibility and prior coverage where applicable.
  • Premium setup: Payroll or billing is updated to reflect plan and effective date.
  • Confirmation: Member receives enrollment confirmation and ID card or welcome materials.

Configuring an online enrollment workflow

Design online workflows to collect required fields, enforce validation, and capture e-signatures in a compliant way.

Field validation Require MM/DD/YYYY and enforce numeric SSN/TIN formats
Required attachments Enable uploads for dependent verification documents
Authentication Use email or SMS codes for signer verification
Audit trail Capture timestamps, IP, and action logs
HIPAA BAA Ensure the eSignature vendor will sign a BAA when PHI is collected

Delivery channels and technical requirements

Choose a platform that supports secure uploads, common file formats, and industry integrations to streamline processing.

  • File formats: PDF, DOCX accepted
  • Integrations: HRIS, Payroll, and CRM systems
  • Authentication: Email, SMS, or stronger methods

Timing considerations and enrollment windows

Deadlines and effective dates vary by plan type, employer policy, and qualifying event; confirm the applicable window before submitting.

Open Enrollment Windows:

Set by employer or exchange; typically occur annually for plan year changes

New hire enrollment:

Employers normally allow a set onboarding period, often 30 days after hire

Special enrollment:

Qualifying events commonly trigger a 30–60 day window to enroll

Coverage effective date:

Subject to plan rules; may be the first day of next month or specified date

Payroll cutoff:

Submit before payroll deadlines to avoid retro premiums

Key milestones from form submission to active coverage

Track these core milestones so you can follow up if processing stalls.

01

Submission recorded

Carrier or broker logs the form and confirms receipt.

02

Eligibility verification

Dependent and prior coverage checks are completed.

03

Premium and payroll setup

Payroll adjustments or billing items are created.

04

Coverage activation

Member receives confirmation and ID materials.

Common mistakes that delay Premera enrollments

  • Missing dependent documentation such as birth certificates or marriage certificates causes verification delays and resubmissions.
  • Incorrect dates of birth or transposed digits in SSN/TIN frequently trigger manual reconciliation with employer records.
  • Unsigned forms or signatures that do not match authorized signer records are typically rejected as incomplete.
  • Submitting forms after payroll or carrier cutoffs can result in retroactive premiums or delayed coverage start dates.

Consequences of incomplete or incorrect enrollment data

Coverage gaps: Delayed benefits activation
Premium errors: Incorrect payroll deductions
Claim denials: Benefits refused for incorrect eligibility
Regulatory risk: HIPAA privacy concerns
Tax reporting: Incorrect W-2/1095 entries
Identity mismatch: Enrollment may be invalidated

Sensitive data elements commonly on the form

Personal identifiers: Full name, DOB, SSN
Contact details: Address, phone, email
Dependent info: Names and DOBs
Plan choices: Selected product codes
Payment details: Payroll deduction instructions
Signature data: Signer name, date, consent

Practical tips to complete forms accurately and quickly

Adopt a standard checklist and validation step to reduce errors and resubmissions.

Use consistent identifiers
Match names and SSNs exactly to employer and government records to avoid delays. Verify spelling and punctuation before submission.
Collect verification documents up front
Attach dependent birth certificates or marriage licenses where required to prevent back-and-forth requests during eligibility checks.
Prefer secure electronic delivery
Use encrypted upload portals and platforms that log timestamps and user authentication to provide an auditable trail for HR and the carrier.
Keep audit copies
Retain a signed copy in HR records and provide members with confirmation of coverage and effective dates for their files.

Real-world examples of online enrollment and eSigning

These brief examples illustrate how organizations handle signings and secure processing at scale.

Fertility Centers of Illinois

Many outpatient clinics needed secure patient consent workflows

  • The organization used eSignature to capture agreements quickly
  • The vendor cited rapid deployment, API integration, and responsive support enabling secure mobile signing for patients and staff.

Martin Properties

A property management firm required remote signing for residents and vendors

  • They moved leases and vendor contracts online
  • The outcome was faster turnaround on documents with consistent audit trails and fewer in-person meetings.

How the Premera Enrollment Form differs from other enrollment documents

Compare common features to understand what the carrier-specific Premera form requires versus general enrollment templates.

Criteria Premera Enrollment Generic Enrollment
E-sign accepted
PHI present varies
Notary required rarely
Consumer disclosure required for consumer-facing records varies

Vendor pricing and feature comparison for eSigning carrier enrollment forms

The table shows starting prices and key capabilities for common eSignature providers. signNow is listed first per comparison convention.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies Varies Varies Varies
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently asked questions about Premera Enrollment Forms and eSigning

Answers to common questions about signatures, attachments, PHI handling, and how to correct or revoke an enrollment submission.


Need help? Contact support

Explore Templates

Parenting Plan Affidavit in Support of Motion to Modify Allocation Petition for Mineral Rights in Montana Child Support Enforcement Division Instructions Notice of Intent to Claim Paternity Notice of Withdrawal of Paternity Acknowledgment
be ready to get more
Join over 28 million airSlate SignNow users
Sign Now
Company
Forms
Pricing
Resources
Knowledge base
Other Products
© 2026 airSlate Inc. All rights reserved.