Blue Cross Registration Form

Individual Registration

Spouse

Dependent 1

Dependent 2

Dependent 3

Dependent 4

Coordination of Benefits

Is the coordination of benefits Single Coverage or Family Coverage? Please indicate for the applicable benefits.

Waiver of Benefits

I have been given the opportunity to apply for coverage but do not wish to participate, and understand that I will not be able to enroll in these plans at a later date without the mutual consent of my employer and Atlantic Blue Cross Care. *Please submit proof of comprehensive coverage with a spousal plan

Employee Authorization

I certify that all information contained hereon is correct and hereby authorize payroll deductions if required.