3108 (W0212) An independent licensee of the Blue Cross and Blue Shield Association. Conversion Request Form (one form per product change) Group Name: _____________________________________________________________________________________ Group Number: ____________________________________ Effective Date: _____ / _____ / ________ Renewal Date (Internal Use Only): _____ / _____ / ________ MM Y Y Y Y D D M M Y Y Y Y D D Broker Name: _____________________________________ Vendor Number: _________________________________ If census is changing, please include enrollment forms for new employees and/or any contract changes for existing members. Please provide employee name and selected Primary Care Physician (if applicable). PCP (if applicable) Current Subgroup # New Subgroup # Employee Name (J or K codes only) (Internal Use Only) (Internal Use Only) * Please note that unless notified, all groups will be set up for one bill option. ** Please submit quote with the Conversion Request Form. Comments: Group Signature: _________________________________________________________ Date: _____ / _____ / ________ MM DD YYYY Account Consultant Signature: ______________________________________________ Date: _____ / _____ / ________ MM DD YYYY You may complete the required fields below online and then save or print a copy for submission. To save a completed copy to your computer, choose File > Save As to rename the file and save the form with your information to your computer.

Conversion Request Form - Martin Ins€¦ · MM DD YYYY MM DD YYYY Broker Name: _ Vendor Number: _ If census is changing, please include enrollment forms for new employees

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Page 1: Conversion Request Form - Martin Ins€¦ · MM DD YYYY MM DD YYYY Broker Name: _____ Vendor Number: _____ If census is changing, please include enrollment forms for new employees

3108 (W0212) An independent licensee of the Blue Cross and Blue Shield Association.

Conversion Request Form(one form per product change)

Group Name: _____________________________________________________________________________________

Group Number: ____________________________________

Effective Date: _____ / _____ / ________ Renewal Date (Internal Use Only): _____ / _____ / ________MM YYYY DD MMYYYY DD

Broker Name: _____________________________________ Vendor Number: _________________________________

If census is changing, please include enrollment forms for new employees and/or any contract changes forexisting members.

Please provide employee name and selected Primary Care Physician (if applicable).

PCP (if applicable) Current Subgroup # New Subgroup #Employee Name (J or K codes only) (Internal Use Only) (Internal Use Only)

* Please note that unless notified, all groups will be set up for one bill option.** Please submit quote with the Conversion Request Form.

Comments:

Group Signature: _________________________________________________________ Date: _____ / _____ / ________MM DD YYYY

Account Consultant Signature: ______________________________________________ Date: _____ / _____ / ________MM DD YYYY

You may complete the required fields below online and then save or print a copy for submission. To save a completed copy to your computer, choose File > Save As to rename the file and save the form with your information to your computer.