Blue Shield of California Individual Family Application C12900-A 1-2011

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  • 8/7/2019 Blue Shield of California Individual Family Application C12900-A 1-2011

    1/12F7:188)GK)G $4%78!

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    http://www.blueinsuranceshield.com/ca_blueshield_get_a_quotehttp://www.blueinsuranceshield.com/ca_blueshield_get_a_quote
  • 8/7/2019 Blue Shield of California Individual Family Application C12900-A 1-2011

    2/12F7:188)GK)G $4%78!

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    Qe{ igq glve x{zfdgvk g mk`}gl xlg` g`m%ez lank a`v{zg`fk }e v{xxlkik`} qe{z ikmafgl fe~kzgbk. XLKGVK @E]K? DAXGG B{gzg`}kkm Avv{k xlg`v gzk `e} klabajlk nez mk`}gl ez lank a`v{zg`fk fe~kzgbk ex}ae`v.

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    Lank A`v{zg`fk ex}ae`v/ $fdkfc e`k!? Gxxlafg`}v {`mkz }dk gbk en e`k qkgz gzk `e} klabajlk nez lank a`v{zg`fk. ]dkvk ex}ae`v gxxlq e`lq }e }dk xzaigzq gxxlafg`}.

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    /[`mkzrza}}k` jq Jl{k Vdaklm en Fglanez`ag Lank Dkgl}d A`v{zg`fk Feixg`q.

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    Nez DIE e`lq, vklkf} g Xkzve`gl Xdqvafag` nez kgfd ngialq ikijkz nzei }dk Jl{k Vdaklm DIE Xdqvafag` g`m Devxa}gl @k}rezc nez qe{z vkz~afk gzkg. Nez w{kv}ae`v, fgll $488! =:=)>;Nez Mk`}gl DIE? vklkf} g Mk`}gl Xze~amkz nzei }dk Mk`}gl DIE Mk`}gl Xze~amkz Mazkf}ezq. Nez w{kv}ae`v zkbgzma`b qe{z Mk`}gl Xze~amkz vklkf}ae`, fgll $488! =67):481.^ava} jl{kvdaklmfg.fei }e na`m g Xkzve`gl Xdqvafag` ez Mk`}gl Xze~amkz.

    Zklg}ae` Vkt Nazv} gik IA Lgv} gik Vefagl Vkf{za}q @{ijkz Mg}k en Jaz}d Dkabd}$n}.a`.!

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    Fe`vamkz iq vxe{vk%meikv}af xgz}`kz nez g vkxgzg}k xlg` f Fdeevk xlg` $fdkfc 7 jet e`lq!? Gffkvv#? f^gl{k DIE fDIE xgfcgbk Jglg`fk xlg`?f7888 f7288 f:;88Kvvk`}agl xgfcgbkv?f72;8 f6888 f=;88 ^a}gl Vdaklm?f188 f:188 ^a}gl Vdaklm Xl{v?f=88 f=88 Bk`kzaf Zt f188 f188 Bk`kzaf Zt f:188 f:188 Bk`kzaf ZtXXE Xlg`?f;888 f;;88 Vdaklm Vg~a`bv?f7488 f6;88 f=888 f;:88 Gf}a~k V}gz}?f:; f:; Bk`kzaf Zt f6; f6; Bk`kzaf ZtJzambk Xlg`? $devxa}gl a`v{zg`fk a`mki`a}q zamkz g~galgjlk nez Vdaklm Vg~a`bv 6;88, =888, g`m ;:88! fMk`}gl Fe~kzgbk?f DIE f XXE f^gl{k Vialk XXE f @e mk`}gl xlg`Mk`}gl DIE e`lq? Mk`}gl xze~amkz &? UUUUUUUUUUUU Mk`}gl xze~amkz `gik? UUUUUUUUUUUUUUUUUUUUUUUUEx}ae`gl Lank A`v{zg`fk? f-78,888 f-68,888 $gbkv 7>=! f->8,888 $gbkv 71>=! f-18,888 $gbkv 71)=1! f-788,888 $gbkv 71)=1!Jk`knafagzq UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

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    Fe`vamkz iq fdalm nez g vkxgzg}k xlg` f Fdeevk xlg` $fdkfc 7 jet e`lq!? Gffkvv#? f^gl{k DIE fDIE xgfcgbk Jglg`fk xlg`?f7888 f7288 f:;88Kvvk`}agl xgfcgbkv?f72;8 f6888 f=;88 ^a}gl Vdaklm?f188 f:188 ^a}gl Vdaklm Xl{v?f=88 f=88 Bk`kzaf Zt f188 f188 Bk`kzaf Zt f:188 f:188 Bk`kzaf ZtXXE Xlg`?f;888 f;;88 Vdaklm Vg~a`bv?f7488 f6;88 f=888 f;:88 Gf}a~k V}gz}?f:; f:; Bk`kzaf Zt f6; f6; Bk`kzaf ZtJzambk Xlg`? $devxa}gl a`v{zg`fk a`mki`a}q zamkz g~galgjlk nez Vdaklm Vg~a`bv 6;88, =888, g`m ;:88! fMk`}gl Fe~kzgbk?f DIE f XXE f^gl{k Vialk XXE f @e mk`}gl xlg`Mk`}gl DIE e`lq? Mk`}gl xze~amkz &? UUUUUUUUUUUU Mk`}gl xze~amkz `gik? UUUUUUUUUUUUUUUUUUUUUUUUEx}ae`gl Lank A`v{zg`fk? f-78,888 f-68,888 Jk`knafagzq UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

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    DIE xlg`v e`lq? Xkzve`gl xdqvafag` `gik? Xze~amkz &? Ikm.bze{x%AXG &? Fdkfc an f{zzk`} xg}ak`

    Fe`vamkz iq fdalm nez g vkxgzg}k xlg` f Fdeevk xlg` $fdkfc 7 jet e`lq!? Gffkvv#? f^gl{k DIE fDIE xgfcgbk Jglg`fk xlg`?f7888 f7288 f:;88Kvvk`}agl xgfcgbkv?f72;8 f6888 f=;88 ^a}gl Vdaklm?f188 f:188 ^a}gl Vdaklm Xl{v?f=88 f=88 Bk`kzaf Zt f188 f188 Bk`kzaf Zt f:188 f:188 Bk`kzaf Zt

    XXE Xlg`?f;888 f;;88 Vdaklm Vg~a`bv?f7488 f6;88 f=888 f;:88 Gf}a~k V}gz}?f:; f:; Bk`kzaf Zt f6; f6; Bk`kzaf ZtJzambk Xlg`? $devxa}gl a`v{zg`fk a`mki`a}q zamkz g~galgjlk nez Vdaklm Vg~a`bv 6;88, =888, g`m ;:88! fMk`}gl Fe~kzgbk?f DIE f XXE f^gl{k Vialk XXE f @e mk`}gl xlg`Mk`}gl DIE e`lq? Mk`}gl xze~amkz &? UUUUUUUUUUUU Mk`}gl xze~amkz `gik? UUUUUUUUUUUUUUUUUUUUUUUUEx}ae`gl Lank A`v{zg`fk? f-78,888 f-68,888 Jk`knafagzq UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

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    Fe`vamkz iq fdalm nez g vkxgzg}k xlg` f Fdeevk xlg` $fdkfc 7 jet e`lq!? Gffkvv#? f^gl{k DIE fDIE xgfcgbk Jglg`fk xlg`?f7888 f7288 f:;88Kvvk`}agl xgfcgbkv?f72;8 f6888 f=;88 ^a}gl Vdaklm?f188 f:188 ^a}gl Vdaklm Xl{v?f=88 f=88 Bk`kzaf Zt f188 f188 Bk`kzaf Zt f:188 f:188 Bk`kzaf ZtXXE Xlg`?f;888 f;;88 Vdaklm Vg~a`bv?f7488 f6;88 f=888 f;:88 Gf}a~k V}gz}?f:; f:; Bk`kzaf Zt f6; f6; Bk`kzaf ZtJzambk Xlg`? $devxa}gl a`v{zg`fk a`mki`a}q zamkz g~galgjlk nez Vdaklm Vg~a`bv 6;88, =888, g`m ;:88! fMk`}gl Fe~kzgbk?f DIE f XXE f^gl{k Vialk XXE f @e mk`}gl xlg`Mk`}gl DIE e`lq? Mk`}gl xze~amkz &? UUUUUUUUUUUU Mk`}gl xze~amkz `gik? UUUUUUUUUUUUUUUUUUUUUUUUEx}ae`gl Lank A`v{zg`fk? f-78,888 f-68,888 Jk`knafagzq UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    Flafc dkzk }e Gxxlq nez Jl{k Vdakln en Fglanez`ag E`la`k

    http://www.blueinsuranceshield.com/ca_blueshield_get_a_quote
  • 8/7/2019 Blue Shield of California Individual Family Application C12900-A 1-2011

    3/12F7:188)GK)G $4%78!

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    Gll w{kv}ae`v i{v} jk fdkfckm $6! Qkv ez @e. G`vrkz gv feixlk}klq g`m gff{zg}klq gv xevvajlk. N{ll mk}galv en g`q Qkv g`vrkzvi{v} jk ba~k` a` Xgz} >.

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    6. Fazf{lg}ezq vqv}ki v{fd gv? ~gzafevk ~ka`v3 xkzaxdkzgl ~gvf{lgz mavkgvk3 xdlkja}av3 jleem fle}v3 v}zeck3 mavkgvk ez mavezmkz en }dk jleem $ktfkx} DA^ a`nkf}ae`!3g`kiag3 k`lgzbkm lqixd `emkv5

    =. Zkvxazg}ezq }zgf} v{fd gv? gv}dig3 zkgf}a~k gazrgq mavkgvk3 jze`fda}av3 gllkzbakv3 va`{va}av3 mavkgvk, mavezmkz ez a`o{zq en }dk l{`bv ez zkvxazg}ezq vqv}ki3 kixdq)vkig3 }{jkzf{levav3 vxa}}a`b ez fe{bda`b {x jleem3 vdez}`kvv en jzkg}d3 x`k{ie`ag3 fqv}af najzevav3 x{lie`gzq najzevav3 fdze`af ejv}z{f}a~k x{lie`gzq mavkgvk3vlkkx gx`kg5 An gv}dig ez gllkzbakv $fazflk nzkw{k`fq!? mgalq, rkkclq, ie`}dlq, vkgve`gl Vk~kza}q $fazflk e`k!? ialm, iemkzg}k, vk~kzk, e}dkz

    ;. G. I{vf{le)vcklk}gl vqv}ki v{fd gv? xga`, a`o{zq, vxzga`, ez e}dkz xzejlkiv en }dk `kfc, vxa`k, ez jgfc3 vfag}afg3 dkz`ag}km ez j{lba`b mavf$v!3 f{z~g}{zk en}dk vxa`k3 vfelaevav3 xga`, a`o{zq, ez e}dkz xzejlkiv en }dk oea`}v, je`kv, ez i{vflkv3 gz}dza}av3 zdk{ig}eam gz}dza}av3 }kixeze)ig`maj{lgz oea`} vq`mzeik$]IO!3 Lqik mavkgvk3 jzeck` je`kv ez zk}ga`km dgzmrgzk3 mavlefg}ae` en oea`}v3 j{`ae`v3 dgiikz}ek3 fgzxgl }{``kl vq`mzeik3 xdqvafgllq dg`mafgxxkm3xelae3 gix{}g}ae`v5

    J. An g`q fdazexzgf}af }zkg}ik`} dgv jkk` zkfka~km, xlkgvk ktxlga` zkgve` nez }zkg}ik`}? UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU@{ijkz en fdazexzgf}af }zkg}ik`}v ra}da` }dk xgv} > ie`}dv? UUUUUUUUUUUU

    >. Ik}gjelaf vqv}ki v{fd gv? magjk}kv3 be{}3 }dqzeam ez gmzk`gl mavezmkzv3 dezie`k ez bzer}d dezie`k mknafak`fakv3 aii{`k vqv}ki mavezmkzv $ktfkx} DA^

    a`nkf}ae`! v{fd gv? l{x{v, Zgq`g{mv, gfw{azkm aii{`k mknafak`fq vq`mzeik $GAMV!, GAMV)zklg}km feixlkt $GZF!, }zkg}ik`} nez GAMV%GZF ra}d G_], DA^AMez Xk`}giama`k }dkzgxq5

    2. Fg`fkz $iglab`g`fq! v{fd gv? lk{ckiag3 Dembca`"v3 iglab`g`} iklg`eig3 }{iez%fqv}3 lqixdeig5 ]qxk? UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUAn Qkv, fazflk }zkg}ik`} }qxk? fdkie}dkzgxq, zgmag}ae` }dkzgxq, e}dkz5

    4. Fe`bk`a}gl gj`ezigla}akv, jaz}d mknkf}v v{fd gv? Mer`v Vq`mzeik3 fkzkjzgl xglvq3 flkn} lax ez xglg}k3 fl{jnee}3 mk~klexik`}gl mklgq3 ez e}dkz `k{zelebafglez xdqvafgl gj`ezigla}akv5

    1. Glfedelavi, mz{b mkxk`mk`fq ez v{jv}g`fk gj{vk ]qxk? UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    78. Fe{`vkla`b ez }zkg}ik`} nez vqix}eiv en mkxzkvvae`3 ig`af mkxzkvvae`3 g`tak}q3 xg`af g}}gfcv3 `kz~e{v`kvv3 ik`}gl ez kie}ae`gl mavezmkzv3 vfdaexdzk`ag3jkdg~aez xzejlkiv3 dqxkzgf}a~a}q3 g}}k`}ae` mknafa} mavezmkz3 kg}a`b mavezmkzv3 j{laiag3 g`ezktag3 glfedel ez v{jv}g`fk gj{vk3 ez nez g`q e}dkz zkgve`5Gzk qe{ f{zzk`}lq a` fe{`vkla`b5 An qkv, zkgve` nez fe{`vkla`b g`m nzkw{k`fq en }zkg}ik`} UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    Dg~k qe{ ez g`q gxxlqa`b ngialq ikijkz a` }dk xgv} ; qkgzv ve{bd} g`q xzenkvvae`gl fe`v{l}g}ae` ez zkfka~km g`q }zkg}ik`} $a`fl{ma`b xzkvfzax}aikmafg}ae`v! nzei g lafk`vkm dkgl}d xzgf}a}ae`kz xkz}ga`a`b }e g`q en }dk nellera`b5

    Gll w{kv}ae`v i{v} jk fdkfckm $6

    ! Qkv ez @e. G`vrkz gv feixlk}klq g`m gff{zg}klq gv xevvajlk. N{ll mk}galv en g`q Qkv g`vrkzvi{v} jk ba~k` a` Xgz} >. QKV

    77. Iglk zkxzem{f}a~k vqv}ki v{fd gv? xzev}g}k xzejlkiv3 aixe}k`fq3 iglk jzkgv} xzejlkiv3 bq`kfeigv}ag3 a`nkf}ae`v3 dkzxkv3 vqxdalav3 be`ezzdkg3 ez e}dkz~k`kzkgl mavkgvk $ktfkx} DA^ a`nkf}ae`!3 ez av ka}dkz }dk gxxlafg`}, vxe{vk ez meikv}af xgz}`kz rdk}dkz ez `e} lav}km e` }dk gxxlafg}ae`, jka`b }zkg}km ezjkk` }zkg}km nez a`nkz}ala}q ra}da` }dk lgv} := ie`}dv5

    7:. G. Nkiglk zkxzem{f}a~k vqv}ki v{fd gv? jzkgv} xzejlkiv3 jzkgv} aixlg`}v3 gmdkvae`v3 gj`ezigl jlkkma`b3 gik`ezzdkg3 iavfgzzagbk g`m%ez gjez}ae`3k`meik}zaevav3 najzeam }{iezv3 gj`ezigl Xgx }kv}3 xzejlkiv en }dk e~gzakv, {}kz{v g`m gvvefag}km nkiglk ezbg`v3 a`)~a}ze nkz}alag}ae`3 a`nkf}ae`v, bk`a}glrgz}v, dkzxkv, vqxdalav, ez e}dkz ~k`kzkgl mavkgvk $ktfkx} DA^ a`nkf}ae`!3 ez av ka}dkz }dk gxxlafg`}, vxe{vk ez meikv}af xgz}`kz rdk}dkz ez `e} lav}km e`}dk gxxlafg}ae`, jka`b }zkg}km ez jkk` }zkg}km nez a`nkz}ala}q ra}da` }dk lgv} := ie`}dv5 ]qxk en aixlg`}v $fazflk e`k!? vgla`k ez valafe`k

    J. Mekv g`q nkiglk gxxlafg`} jk}rkk` }dk gbkv en 7:);; ik`v}z{g}k5

    7. An qkv, lav} }dk `gikv en ngialq ikijkz$v!? UUUUUUUUUUUUUUUUUUUUUUUUUU3 UUUUUUUUUUUUUUUUUUUUUUUUU3 UUUUUUUUUUUUUUUUUUUUUU

    :. Dgv a} jkk` iezk }dg` =8 mgqv va`fk dkz%}dkaz lgv} ik`v}z{gl xkzaem5 UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    6. An Qkv, lav} }dk `gikv en ngialq ikijkz$v!? UUUUUUUUUUUUUUUUUUUUUUUUUU3 UUUUUUUUUUUUUUUUUUUUUUUUU3 UUUUUUUUUUUUUUUUUUUUUU

    =. Xlkgvk ktxlga`? UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    76. Mabkv}a~k vqv}ki v{fd gv? mavkgvk ez mavezmkz en }dk ie{}d, }e`b{k, kvexdgb{v ez v}eigfd3 {lfkz3 bgll jlgmmkz mavezmkz3 la~kz mavkgvk3 fazzdevav3 og{`mafk3gvfa}kv3 xg`fzkg}a}av3 fele`, a`}kv}a`gl ez zkf}gl xzejlkiv3 fela}av3 fdze`af magzzdkg3 dkiezzdeamv3 dkz`ag3 rkabd} ez kg}a`b xzejlkiv3 dkxg}a}av5An dkxg}a}av, }qxk$v!? G, J, F, e}dkz

    7=. [za`gzq }zgf} v{fd gv? zk`gl felaf3 bzg~kl ez v}e`kv3 {zk}dzg, jlgmmkz, {zk}kz ez cam`kq xzejlkiv3 {za`gzq }zgf} a`nkf}ae`v3 v}zaf}{zk3 xqkle`kxdza}av5

    7;. Vca` fe`ma}ae`v v{fd gv? vca` fg`fkz3 iklg`eig3 xvezagvav3 ckzg}evav3 gf`k3 dkzxkv3 rgz}v3 jaz}digzcv3 vk~kzk j{z`v5

    7>. Mavkgvkv ez xzejlkiv en }dk kqkv ez vabd}, kgzv ez dkgza`b, `evk ez jzkg}da`b, }dzeg} ez vrgllera`b v{fd gv? g`q a`nkf}ae`v en kqkv, kgzv, `evk ez }dzeg}3fzevvkm kqkv3 blg{feig3 fg}gzgf}v3 mk}gfdkm zk}a`g3 xelqxv3 mk~ag}km `gvgl vkx}{i3 ktfkvva~k v`eza`b3 xzejlkiv ra}d }e`valv ez gmk`eamv3 vlkkx gx`kg5

    72. Gj`ezigl lgjezg}ezq zkv{l}v v{fd gv jleem rezc3 t)zgqv3 KCB3 `kz~k fe`m{f}ae`3 jleem nler v}{makv3 IZA, F], XK] ez e}dkz vfg`v$v! $ktfkx} DA^ g`}ajemqmk}kf}ae` }kv}v!5

    74. Xzev}dkvav, aixlg`}, ez zk}ga`km dgzmrgzk5 ]qxk? UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    Flafc dkzk }e Gxxlq nez Jl{k Vdaklm en Fglanez`ag E`la`k

    http://www.blueinsuranceshield.com/ca_blueshield_get_a_quote
  • 8/7/2019 Blue Shield of California Individual Family Application C12900-A 1-2011

    4/12F7:188)GK)G $4%78!

    xGz} ; f{zzk`} ez zkfk`} xzkVfzax}ae` ikmafG}ae`V

    An qe{ g`vrkzkm QKV }e w{kv}ae` 71 a` Xgz} =, xlkgvk xze~amk }dk mk}galv en }dk f{zzk`} g`m xzk~ae{v ikmafg}ae`v. An gmma}ae`gl vxgfk av kfkvvgzq }e xze~amk feixlk}k a`nezig}ae`, xlkg}}gfd g` gmma}ae`gl vdkk} en xgxkz. Jk v{zk }e amk`}anq }dk ngialq ikijkz, a`fl{mk gll a`nezig}ae` zkw{kv}km g`m vab g`m mg}k k~kzq g}}gfdik`}. Fdkfc dkzk nez g}}gfdik`}. f

    @gik en ngialq ikijkz Mg}kv nzei? UUUUU%UUUUU%UUUUU }e? UUUUU%UUUUU%UUUUU

    Ikmafg}ae` Zkgve` nez Zt Mevgbk Nzkw{k`fq

    Xdqvafag` @gik Xde`k {ijkz Ikmafgl bze{x Xdqvafag` vxkfagl}q

    Gmmzkvv V}k & Fa}q V}g}k _AX

    @gik en ngialq ikijkz Mg}kv nzei? UUUUU%UUUUU%UUUUU }e? UUUUU%UUUUU%UUUUU

    Ikmafg}ae` Zkgve` nez Zt Mevgbk Nzkw{k`fq

    Xdqvafag` @gik Xde`k {ijkz Ikmafgl bze{x Xdqvafag` vxkfagl}q

    Gmmzkvv V}k & Fa}q V}g}k _AX

    @gik en ngialq ikijkz Mg}kv nzei? UUUUU%UUUUU%UUUUU }e? UUUUU%UUUUU%UUUUU

    Ikmafg}ae` Zkgve` nez Zt Mevgbk Nzkw{k`fq

    Xdqvafag` @gik Xde`k {ijkz Ikmafgl bze{x Xdqvafag` vxkfagl}q

    Gmmzkvv V}k & Fa}q V}g}k _AX

    Gxxlafg`}v Vefagl Vkf{za}q @{ijkUUUUU UUUUU UUUUU ) UUUUU UUUUU ) UUUUU UUUUU UUUUU

    xGz} = ikmafGl daV}ezq $fe`}a`{km! Xlkgvk g`vrkz GLL w{kv}ae`v. Zkikijkz }e a`a}agl g`q fdg`bkv%fezzkf}ae`v qe{ igq dg~k }e igck gv qe{feixlk}k }dk w{kv}ae``gazk.

    Gll w{kv}ae`v i{v} jk fdkfckm $6! Qkv ez @e. G`vrkz gv feixlk}klq g`m gff{zg}klq gv xevvajlk. N{ll mk}galv en g`q Qkv g`vrkzvi{v} jk ba~k` a` Xgz} >.

    QKV

    71. Dg~k qe{ ez g`q gxxlqa`b ngialq ikijkz }gck` ez jkk` rza}}k` g xzkvfzax}ae` nez ikmafg}ae`$v! a` }dk lgv} 7: ie`}dv5 An qkv, xlkgvk nall e{} Xgz} ;en }dav gxxlafg}ae`.

    :8. A` }dk xgv} ; qkgzv, dg~k qe{ ez g`q gxxlqa`b ngialq ikijkz?

    G. Jkk` g` a`xg}ak`} ez e{}xg}ak`} a` g devxa}gl, v{zbafgl fk`}kz, vg`a}gza{i, ez e}dkz ikmafgl ngfala}q, a`fl{ma`b g` kikzbk`fq zeei, ez dgm v{zbkzq,a`fl{ma`b g`baexlgv}q, fevik}af%zkfe`v}z{f}a~k, jqxgvv ez }zg`vxlg`} v{zbkzq5

    J. Dgm g`q all`kvv, xdqvafgl a`o{zq, xkzvav}a`b ez `kr xdqvafgl vqix}eiv g`m%ez dkgl}d xzejlkiv `e} ik`}ae`km klvkrdkzk e` }dav gxxlafg}ae` }dg} dg~k`e} jkk` k~gl{g}km ez }dg} qe{ xlg` }e dg~k k~gl{g}km jq g lafk`vkm dkgl}d xzgf}a}ae`kz5

    F. Jkk` gm~avkm }e dg~k, ez jkk` zknkzzkm nez, g ikmafgl ktgi, n{z}dkz }kv}a`b, }zkg}ik`} ez v{zbkzq rdafd dgv `e} qk} jkk` xkznezikm jq g xdqvafag`,mk`}av}, ez e}dkz lafk`vkm dkgl}d xzgf}a}ae`kz5

    M. Dgm g`q gxxlafg}ae` nez dkgl}d ez lank a`v{zg`fk zk~eckm, mkfla km, mknkzzkm, xev}xe`km, ez zkv}zaf}km a` g`q rgq5

    Ngialq ikijkz? UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUMg}k?UUUUU%UUUU%UUUU

    Xlkgvk ktxlga`? UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    :7. Gzk qe{ ez g`q gxxlqa`b ngialq ikijkz xzkvk`}lq g ikijkz en g v{xxez} bze{x5 ]qxk? UUUUUUUUUUUUUUUUUUUUUUUDer Le`b?UUUUUUUUUUU

    ::. Iglkv e`lq? Gzk qe{ ktxkf}a`b g fdalm ra}d g`qe`k, k~k` an }dk jaz}d ie}dkz av `e} lav}km e` }dk gxxlafg}ae`5

    :6. Iglkv g`m nkiglkv? Av ka}dkz }dk gxxlafg`}, vxe{vk, meikv}af xgz}`kz ez mkxk`mk`}, rdk}dkz ez `e} lav}km e` }dk gxxlafg}ae`, f{zzk`}lq xzkb`g`},ez a` }dk xzefkvv en gmex}ae` ez v{zzebg}k xzkb`g`fq5

    :=. Dg~k ez me qe{ ez g`q gxxlqa`b ngialq ikijkz?

    G. Zkw{kv}km ez zkfka~km g xk`vae`, jk`kna}v ez xgqik`} jkfg{vk en g`q a`o{zq, vafc`kvv, mavgjala}q en rezckzv feixk`vg}ae`5

    J. Vieck$m! fabgzk}}kv5 Ngialq ikijkz? UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU Der ig`q xgfcv xkz mgq? UUUUUUUUUUUUU

    Nez der ig`q qkgzv? UUUUUUUUU Dg~k qe{%}dkq v}exxkm5 UUUUUUUUUU An qkv, rdk`5UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    F. Mza`c glfedelaf jk~kzgbkv5 Ngialq ikijkz? UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU @{ijkz en mza`cv xkz rkkc? UUUUUUUUUUUUUUU

    Nez der ig`q qkgzv? UUUUUUUUUU Dg~k qe{%}dkq v}exxkm5 UUUUUUUUUUU An qkv, rdk`5 UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    Flafc dkzk }e Gxxlq nez Jl{k Vdaklm en Fglanez`ag

    http://www.blueinsuranceshield.com/ca_blueshield_get_a_quote
  • 8/7/2019 Blue Shield of California Individual Family Application C12900-A 1-2011

    5/12F7:188)GK)G $4%78!

    Gxxlafg`}v Vefagl Vkf{za}q @{ijkUUUUU UUUUU UUUUU ) UUUUU UUUUU ) UUUUU UUUUU UUUUU

    xGz} > ikmafGl fe`ma}ae` mk}GalV An e{ g`rkzkm qv }e g` en w{k}ae` 7:= ra}d }dk ktfkx}ae` en 71, :8, :=Jg`m :=F a` Xgz} =, bak n{ll mk}gal jkler nez kgfd fe`ma}ae`

    An gmma}ae`gl vxgfk av `kfkvvgzq }e xze~amk feixlk}k a`nezig}ae`, xlkgvk g}}gfd g` gmma}ae`gl vdkk} en xgxkz. Jk v{zk }e amk`}anq }dk ngialq ikijkz, }dk vkf}ae` g`m }dkw{kv}ae` `{ijkz, gv gxxzexzag}k, a`fl{mk gll a`nezig}ae` zkw{kv}km a` Xgz} > g`m vab` g`m mg}k k~kzq g}}gfdik`}. Fdkfc dkzk nez g}}gfdik`}.f

    Lav}w{kv}ae``{ijkz

    Ngialq ikijkz `gikg`m `gik {vkm e` mef}ez"v zkfezmv?

    Magb`evav? ]zkg}ik`}?

    Nazv}? Mg}kv en }zkg}ik`}?

    Jkbg`? UUUU %UUUU $IE%QZ! K`mkm? UUUU %UUUU $IELgv}?

    Mekv }dk fe`ma}ae` v}all ktav}5 f Qkv f @e Fe`ma}ae`"v xzkvk`} v}g}{v?

    Ikmafgl AM fgzm & $an g~galgjlk! Devxa}glakm5 f Qkv f @e Mg}kv?

    KZ ~ava}v5 f Qkv f @e Mg}kv?

    N{ll `gik g`m gmmzkvv en k~kzq xdqvafag`, fla`af ez devxa}gl $a`fl{mk _AX femk!. Nez xdqvafag`v rde jkle`b }e g ikmafgl bze{x, xlkgvk lav} }dk ikmafgl bze{x gv rkll

    @gik? Xde`k `{ijkz? $ ! Ikmafgl bze{x

    Gmmzkvv? V}k &

    Fa}q V}g}k _AX

    Lav}w{kv}ae`

    `{ijkz

    Ngialq ikijkz `gikg`m `gik {vkm e` mef}ez"v zkfezmv?

    Magb`evav? ]zkg}ik`}?

    Nazv}? Mg}kv en }zkg}ik`}?Jkbg`? UUUU %UUUU $IE%QZ! K`mkm? UUUU %UUUU $IELgv}?

    Mekv }dk fe`ma}ae` v}all ktav}5 f Qkv f @e Fe`ma}ae`"v xzkvk`} v}g}{v?

    Ikmafgl AM fgzm & $an g~galgjlk! Devxa}glakm5 f Qkv f @e Mg}kv?

    KZ ~ava}v5 f Qkv f @e Mg}kv?

    N{ll `gik g`m gmmzkvv en k~kzq xdqvafag`, fla`af ez devxa}gl $a`fl{mk _AX femk!. Nez xdqvafag`v rde jkle`b }e g ikmafgl bze{x, xlkgvk lav} }dk ikmafgl bze{x gv rkll

    @gik? Xde`k `{ijkz? $ ! Ikmafgl bze{x

    Gmmzkvv? V}k &

    Fa}q V}g}k _AX

    Lav}

    w{kv}ae``{ijkz

    Ngialq ikijkz `gikg`m `gik {vkm e` mef}ez"v zkfezmv?

    Magb`evav? ]zkg}ik`}?

    Nazv}? Mg}kv en }zkg}ik`}?

    Jkbg`? UUUU %UUUU $IE%QZ! K`mkm? UUUU %UUUU $IELgv}?

    Mekv }dk fe`ma}ae` v}all ktav}5 f Qkv f @e Fe`ma}ae`"v xzkvk`} v}g}{v?

    Ikmafgl AM fgzm & $an g~galgjlk! Devxa}glakm5 f Qkv f @e Mg}kv?

    KZ ~ava}v5 f Qkv f @e Mg}kv?

    N{ll `gik g`m gmmzkvv en k~kzq xdqvafag`, fla`af ez devxa}gl $a`fl{mk _AX femk!. Nez xdqvafag`v rde jkle`b }e g ikmafgl bze{x, xlkgvk lav} }dk ikmafgl bze{x gv rkll

    @gik? Xde`k `{ijkz? $ ! Ikmafgl bze{x

    Gmmzkvv? V}k &

    Fa}q V}g}k _AX

    Lav}w{kv}ae``{ijkz

    Ngialq ikijkz `gik

    g`m `gik {vkm e` mef}ez"v zkfezmv?

    Magb`evav? ]zkg}ik`}?

    Nazv}? Mg}kv en }zkg}ik`}?

    Jkbg`? UUUU %UUUU $IE%QZ! K`mkm? UUUU %UUUU $IELgv}?

    Mekv }dk fe`ma}ae` v}all ktav}5 f Qkv f @e Fe`ma}ae`"v xzkvk`} v}g}{v?

    Ikmafgl AM fgzm & $an g~galgjlk! Devxa}glakm5 f Qkv f @e Mg}kv?

    KZ ~ava}v5 f Qkv f @e Mg}kv?

    N{ll `gik g`m gmmzkvv en k~kzq xdqvafag`, fla`af ez devxa}gl $a`fl{mk _AX femk!. Nez xdqvafag`v rde jkle`b }e g ikmafgl bze{x, xlkgvk lav} }dk ikmafgl bze{x gv rkll

    @gik? Xde`k `{ijkz? $ ! Ikmafgl bze{x

    Gmmzkvv? V}k &

    Fa}q V}g}k _AX

    Flafc dkzk }e Gxxlq nez Jl{k Vdaklm en Fglanez`ag

    http://www.blueinsuranceshield.com/ca_blueshield_get_a_quote
  • 8/7/2019 Blue Shield of California Individual Family Application C12900-A 1-2011

    6/12F7:188)GK)G $4%78!

    xGz} 4 xzaez ikmafGl fe~kzGbk Xlkgk g`rkz kgfd w{k}ae`

    7. Mam qe{ ez g`q gxxlqa`b ngialq ikijkz dg~k e}dkz dkgl}d fe~kzgbk $a`v{zg`fk! ra}da` }dk lgv} >6 mgqv5 f QV f @

    An `e, be }e Xgz} 1An qkV, feixlk}k }dk nellera`b?

    qxk en Fe~kzgbk nnkf}a~k mg}k? Fg`fkl mg}k? Dkgl}d xlg` fgzzakz ez FEJZ gmia`av}zg}ez:. Gxxlafg`} f Bze{x f FG UUUU%UUUU%UUUU UUUU%UUUU%UUUU UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU f A`ma~am{gl f }dkzVxe{vk%Meikv}af Xgz}`kz%Mkxk`mk`} f Bze{x f FG UUUU%UUUU%UUUU UUUU%UUUU%UUUU UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU f A`ma~am{gl f }dkz

    6. An qe{ gzk gxxlqa`b nez g xlg` e}dkz }dg` g` DI, mam qe{ dg~k g xzaez dkgl}d xlg` }dg} fe~kzkm g`q en }dk fe`ma}ae`v fdkfckm qkva` Xgz} =5 fqv f`An }dg} xlg` }kzia`g}km ra}da` >6 mgqv en }dk l{k Vdaklm zkfkax} mg}k en }dav gxxlafg}ae`, xlkgvk fdkfc dkzkf g`m v{jia} g fkz}anafg}k en fzkma}gjlkfe~kzgbk nzei qe{z xzk~ae{v dkgl}d fgzzakz. An qe{z gxxlafg}ae` av gxxze~km, rk rall gxxlq qe{z xzaez fzkma}gjlk fe~kzgbk }e zkm{fk g`q rga}a`b xkzaemqe{z xzk)ktav}a`b fe`ma}ae ktfl{vae` ra}d }dav xlg`. ]dk xzk)ktav}a`b fe`ma}ae` ktfl{vae` mekv `e} gxxlq }e mkxk`mk`}v {`mkz }dk gbk en 71. Vkk }dk

    V{iigzq en k`kna}v jeeclk} nez iezk e` xzk)ktav}a`b fe`ma}ae`v. Qe{ fg` fgll l{k Vdaklm g} $488! =67):481 nez gvvav}g`fk ej}ga`a`b g fkz}anafg}k.

    =. An qe{ gzk gxxlqa`b nez g` DI Xlg`, xlkgvk `e}k }dg} xzkb`g`fq av g Rga~kzkm Fe`ma}ae`. k`kna}v nez xzkb`g`fq g`m ig}kz`a}q vkz~afkv gzk`e} fe~kzkm m{za`b }dk vat $>!)ie`}d xkzaem jkba``a`b gv en }dk knnkf}a~k mg}k en fe~kzgbk an qe{ zkfka~km xzkb`g`fq)zklg}km ikmafgl gm~afk,magb`evav, fgzk ez }zkg}ik`}, a`fl{ma`b xzkvfzax}ae` mz{bv, nzei g lafk`vkm dkgl}d xzgf}a}ae`kz m{za`b }dk vat ie`}dv aiikmag}klq xzkfkma`b }dknnkf}a~k mg}k en fe~kzgbk, ra}d }dk ktfkx}ae` en vkz~afkv zkw{azkm }e }zkg} a`~el{`}gzq feixlafg}ae`v en xzkb`g`fq. Derk~kz, an qe{ dg~k xzaefzkma}gjlk fe~kzgbk, g`m qe{ gxxlq nez fe~kzgbk ra}da` >6 mgqv gn}kz }kzia`g}ae` en }dk xzaez fe~kzgbk, l{k Vdaklm rall fzkma} }dk lk`b}d en }qe{ rkzk fe~kzkm e` qe{z xzk~ae{v dkgl}d xlg` }ergzm }dk vat)ie`}d xkzaem. Vkk }dk V{iigzq en k`kna}v jeeclk} nez iezk e` rga~kzkmfe`ma}ae`v. Qe{ fg` fgll l{k Vdaklm g} $488! =67):481 nez gvvav}g`fk ej}ga`a`b g fkz}anafg}k.

    vEX'' R E XA DAv XXAFAE5 R E ~EA XEvvAJ ZZEZv RDAFD Fv qv A FFXF5

    c E qEZ JE FEiXA DAv NEZi EA'

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    Dg~k qe{ g`m%ez g`q gxxlqa`b ngialq ikijkz ~ava}km g xdqvafag`, xvqfdag}zav}, fdazexzgf}ez, xdqvafag` gvvav}g`}, `{zvk xzgf}a}ae`kz, xdqvafgl }dkzgxav}ez e}dkz lafk`vkm dkgl}d xzgf}a}ae`kz a` }dk xgv} ; qkgzv5 An Qkv, k`}kz }dk mk}galv jkler. An @e, fdkfc dkzk f g`m be }e Xgz} 4.@e}k? Ktgiv nez fdalmzk` {`mkz ; qkgzv en gbk gzk zkw{azkm. Ikmafgl Zkfezmv rall jk zkw{kv}km nez GLL fdalmzk` gbk vk~k` $2! ie`}dv g`m qe{`bkz

    @gik en gxxlafg`} Mg}k en ~ava}?

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    Xdqvafag` `gik Xde`k {ijkz Ikmafgl bze{x Xdqvafag` vxkfagl}q

    Gmmzkvv V}k & Fa}q V}g}k _AX

    @gik en vxe{vk%meikv}af xgz}`kz Mg}k en ~ava}?

    UUUU%UUUU%UUUUU

    Zkgve` nez ktgi Zkv{l}v Xzkvk`} v}g}{v

    Xdqvafag` `gik Xde`k {ijkz Ikmafgl bze{x Xdqvafag` vxkfagl}q

    Gmmzkvv V}k & Fa}q V}g}k _AX

    @gik en mkxk`mk`} Mg}k en ~ava}?

    UUUU%UUUU%UUUUU

    Zkgve` nez ktgi Zkv{l}v Xzkvk`} v}g}{v

    Xdqvafag` `gik Xde`k `{ijkz Ikmafgl bze{x Xdqvafag` vxkfagl}q

    Gmmzkvv V}k & Fa}q V}g}k _AX

    @gik en mkxk`mk`} Mg}k en ~ava}?

    UUUU%UUUU%UUUUU

    Zkgve` nez ktgi Zkv{l}v Xzkvk`} v}g}{v

    Xdqvafag` gik Xde`k {ijkz Ikmafgl bze{x Xdqvafag` vxkfagl}q

    Gmmzkvv V}k & Fa}q V}g}k _AX

    Flafc dkzk }e Gxxlq nez Jl{k Vdaklm en Fglanez`ag

    http://www.blueinsuranceshield.com/ca_blueshield_get_a_quote
  • 8/7/2019 Blue Shield of California Individual Family Application C12900-A 1-2011

    7/12F7:188)GK)G $4%78!

    Gxxlafg`}v Vefagl Vkf{za}q @{ijkUUUUU UUUUU UUUUU ) UUUUU UUUUU ) UUUUU UUUUU UUUUU

    E NEZ qEZ vAZ Eqv Z ZWAZ D EN XZ 1 78 EN DAv XXAFAE

    xGz} 1 G{}dezaG}ae` nez zklkGVk en a`neziG}ae`

    q vab`a`b }dav nezi qe{ gzk g{}dezaa`b }dk zklkgvk en qe{z g`m%ez qe{z mkxk`mk`}v dkgl}dfgzk a`nezig}ae` jq g dkgl}dfgzk xze~amkz, a`v{zkz, a`v{zg`fk v{xxez} ezbg`ag}ae` ezbg`ag}ae`$rdafd a`fl{mkv fe`v{ikz zkxez}a`b gbk`fakv!, dkgl}d xlg`, ez qe{z a`v{zg`fk gbk`}, }el{k Vdaklm en Fglanez`ag ez l{k Vdaklm en Fglanez`ag Lank Dkgl}d A`v{zg`fk Feixg`q $fellkf)}a~klq, l{k Vdaklm! nez }dk x{zxevk en zk~akra`b qe{z gxxlafg}ae` nez l{k Vdaklm fe~kzgbk.

    N{z}dkz, jq vab`a`b }dav nezi qe{ gzk g{}dezaa`b l{k Vdaklm }e mavflevk v{fd dkgl}dfgzka`nezig}ae` }e g dkgl}dfgzk xze~amkz, a`v{zkz, vkln)a`v{zkz, a`v{zg`fk v{xxez} ezbg`ag}ae`,dkgl}d xlg`, ez qe{z a`v{zg`fk gbk`} nez }dk x{zxevk en a`~kv}abg}a`b ez k~gl{g}a`bg`q flgai nez jk`k}v. ]dk dkgl}dfgzk a`nezig}ae` {vkm ez mavflevkm x{zv{g`} }e }davg{}dezag}ae` igq jk v{jokf} }e zk)mavflev{zk g`m igq `e le`bkz jk xze}kf}km {`mkz }dknkmkzgl dkgl}d a`nezig}ae` xza~gfq lgrv.

    Qe{ dg~k }dk zabd} }e zkn{vk }e vab` }dav g{}dezag}ae`. Derk~kz, l{k Vdaklm dgv }dk zabd}}e fe`ma}ae` qe{z g`m%ez qe{z mkxk`mk`}v klabajala}q nez fe~kzgbk g`m k`zellik`}mk}kzia`g}ae`v {xe` zkfkax} en }dav vab`km g{}dezag}ae`.

    Qe{ gzk k`}a}lkm }e g fexq en }dav G{}dezag}ae` gn}kz qe{ vab` a}.

    txazg}ae`? ]dav g{}dezag}ae` rall zkiga` ~glam? 7! nez }daz}q $68! ie`}dv nzei }dk mg}k en}dav g{}dezag}ae` nez }dk x{zxevkv en xzefkvva`b qe{z gxxlafg}ae`, xzefkvva`b g zkw{kv} nezzka`v}g}kik`}, ez xzefkvva`b g zkw{kv} nez g fdg`bk a` jk`k}v3 :! nez gv le`b gv igq jk

    `kfkvvgzq nez xzefkvva`b en flgaiv a`f{zzkm m{za`b }dk }kzi en fe~kzgbk3 g`m 6! nez }dk}kzi en fe~kzgbk nez gll e}dkz gf}a~a}akv {`mkz }dk dkgl}d vkz~afkv gbzkkik`}%xelafq.

    abd} }e k~eck? A {`mkzv}g`m }dg} A igq zk~eck }dav g{}dezag}ae` g} g`q }aik jqba~a`b rza}}k` `e}afk en iq zk~efg}ae` }e l{k Vdaklm. A {`mkzv}g`m }dg} zk~efg}ae` en}dav g{}dezag}ae` rall `e} gnnkf} g`q gf}ae` l{k Vdaklm dgv }gck` a` zklag`fk e` }davg{}dezag}ae` xzaez }e zkfka~a`b iq rza}}k` `e}afk en zk~efg}ae`.

    Gxxlafg`}%Xgzk`} $ez lkbgl b{gzmag`!

    TUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    ]emgqv mg}k

    UUUUUUUUU%UUUUUUUUU%UUUUUUUUUUUU

    Gxxlafg`}v vxe{vk%meikv}af xgz}`kz

    TUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    ]emgqv mg}k

    UUUUUUUUU%UUUUUUUUU%UUUUUUUUUUUU

    Gxxlafg`} gbk 74 g`m e~kz

    TUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    ]emgqv mg}k

    UUUUUUUUU%UUUUUUUUU%UUUUUUUUUUUU

    Gxxlafg`} gbk 74 g`m e~kz

    TUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    ]emgqv mg}k

    UUUUUUUUU%UUUUUUUUU%UUUUUUUUUUUU

    Flafc dkzk }e Gxxlq nez Jl{k Vdakln en Fglanez`ag E`la`k

    http://www.blueinsuranceshield.com/ca_blueshield_get_a_quote
  • 8/7/2019 Blue Shield of California Individual Family Application C12900-A 1-2011

    8/12F7:188)GK)G $4%78!

    Gxxlafg`}v Vefagl Vkf{za}q @{ijkUUUUU UUUUU UUUUU ) UUUUU UUUUU ) UUUUU UUUUU UUUUU

    xGz} 78 G{}dezaG}ae`V, }kziV . fe`ma}ae`Vxgv g r v g v g qe{z g{}dezag}ae` g`m ab`g}{zk gzk zkw{azkm jkler

    7. Gg fg? A} av aixez}g`} }e c`er }dg} l{k Vdaklm en Fglanez`ag ez l{k Vdaklm en Fglanez`ag Lank Dkgl}d A`v{zg`fk Feixg$gv gxxlafgjlk! dgv }dk zabd} }e mkfla`k qe{z gxxlafg}ae` nez fe~kzgbk. `? A {`mkzv}g`m }dg} l{k Vdaklm igq {vk g`q ikmafgl a`nezig}ae`a` zk~akra`b iq gxxlafg}ae`, a`fl{ma`b g`q ikmafgl fe`ma}ae` rdafd eff{zv gn}kz }dk vab`g}{zk g`m v{jiavvae` en }dk gxxlafg}ae` g`m jknezkg mkfavae` jq [`mkzrza}a`b av igmk.

    :. nv iv mv%xv? G}}gfd g xkzve`gl fdkfc ez ie`kq ezmkz }e }dav gxxlafg}ae` a` g` gie{`} kw{gl }e e`k ie`}dvM{kv%Xzkia{iv. Na`m qe{z kv}aig}km ie`}dlq m{kv%xzkia{iv a` }dk zg}k jeec xze~amkm }e qe{. Ngal{zk }e v{jia} n{ll xgqik`}en M{kv%Xzkia{iv igq mklgq xzefkvva`b g`m }dk knnkf}a~k mg}k en fe~kzgbk. Xlkgvk `e}k }dg} fgvda`b en qe{z fdkfc mekv `e} fe`v}a}{}kgxxze~gl en qe{z gxxlafg}ae` ra}d l{k Vdaklm ez l{k Vdaklm Lank. An qe{z gxxlafg}ae` av `e} gxxze~km, }dav gie{`} rall jk zkn{`mkm }e qe{.

    6. mv%xv? M{kv%Xzkia{iv gzk }e jk xgam jq }dk nazv} mgq en }dk jalla`b xkzaem. Fe~kzgbk rall jk }kzia`g}km nez ngal{zk }e xgqM{kv%Xzkia{iv a` g }aiklq ig``kz gv vk} nez}d a` }dk Dkgl}d Vkz~afk Gbzkkik`}%Xelafq.

    =. k mg fg? An qe{z gxxlafg}ae` av gxxze~km, l{k Vdaklm rall `e}anq qe{ en qe{z knnkf}a~k mg}k en fe~kzgbk. An l{k Vdaklmfg``e} de`ez qe{z zkw{kv}km knnkf}a~k mg}k, ez av {`gjlk }e avv{k fe~kzgbk jknezk qe{z zkw{kv}km mg}k, fe~kzgbk rall jkba` gv vee` gv xevvajAn gmma}ae`gl M{kv%Xzkia{iv gzk erkm, xgqik`} i{v} jk zkfka~km ra}da` }dk }aik vxkfanakm a` }dk `e}afk nzei l{k Vdaklm }e g~eam fdg`ba`b}dk knnkf}a~k mg}k. G`q fdgzbkv a`f{zzkm nez vkz~afkv zkfka~km xzaez }e qe{z knnkf}a~k mg}k ez gn}kz }kzia`g}ae` en fe~kzgbk gzk `e} fe~kzkm.

    ;. k G? An gxxze~km, }dav gxxlafg}ae` $a`fl{ma`b }dk dkgl}d w{kv}ae``gazk!, }ebk}dkz ra}d }dk k~amk`fk en fe~kzgbk g`m dkgl}dvkz~afkv gbzkkik`}%xelafq nez a`ma~am{glv g`m ngialakv, g`q k`mezvkik`}v, gxxk`mafkv, g`m g}}gfdik`}v }dkzk}e, rall fellkf}a~klq fe`v}a}{}k }dk`}azk gbzkkik`} nez fe~kzgbk. Qe{z gbk`} fg``e} gxxze~k }dav gxxlafg}ae` nez fe~kzgbk ez fdg`bk g`q }kziv ez fe`ma}ae`v en fe~kzgbk.

    >. xgv%bggv? An qe{ gzk }dk xgzk`} ez lkbgl b{gzmag` en g` gxxlafg`} rde av g ia`ez, xlkgvk vab` e` jkdgln en }dk gxxlafg`} g} }dk je})}ei en }dav Xgz} 78. Gv }dk xgzk`} ez lkbgl b{gzmag`, qe{ gzk amk`}anakm gv }dk xkzve` rde igq igck a`w{azakv g`m gf} e` jkdgln en }dk gxxlafg`}

    zkbgzma`b }dav fe~kzgbk $gv gllerkm jq lgr!. A` gmma}ae`, qe{ gzk gbzkka`b }e gvv{ik gll zkvxe`vajala}q nez M{kv%Xzkia{iv xgqik`}v g`m nez nellera`b }dk }kziv g`m fe`ma}ae`v nez fe~kzgbk. An qe{ gzk `e} }dk xgzk`} en }dk gxxlafg`}, xlkgvk g}}gfd }dk fe{z} mef{ik`}v }dg} gxxea`} qe{ gv }dkb{gzmag` en }dav ia`ez. Igzc e`k en }dk nellera`b jetkv g`m amk`}anq }dk a`ma~am{gl g{}dezakm }e gf} e` jkdgln en }dk ia`ez $gxxlafg`}!?

    Xgzk`} ez lkbgl b{gzmag` e`lq?UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU $`gik! ez,

    Iq mkvab`kkUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU $a`fl{mk `gik g`m zklg}ae`vdax!

    W{glanakm Ikmafgl Fdalm V{xxez} zmkz mkvab`kkUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU $a`fl{mk `gik g`m zklg}ae`vd

    Igzc }dav jet an l{k Vdaklm av }e e`lq igck fdg`bkv }e }dk fe`}zgf} {xe` rza}}k` zkw{kv} jq }dk xkzve` amk`}anakm gje~k.

    2. Gg Vv%mv xg ig fgv? An qe{ gzk g` gxxlafg`} rdevk vxe{vk%meikv}af xgz}`kz av glve gxxlqa`bnez fe~kzgbk, xlkgvk vxkfanq an qe{ g{}dezak qe{z vxe{vk%meikv}af xgz}`kz }e igck gmma}ae`v ez fdg`bkv }e }dk gxxlafg}ae`%fe`}zgf}%xelafqe` qe{z jkdgln. Qkv. @e. `? Qe{ igq mavfe`}a`{k }dav g{}dezag}ae` g} g`q }aik jq vk`ma`b g rza}}k` zkw{kv} }e l{k Vdaklm.

    4. zvv zwv ag? Qe{ gbzkk }e feexkzg}k ra}d l{k Vdaklm $ez l{k Vdaklm Lank, gv gxxlafgjlk! jq xze~ama`b, ez jq xze)~ama`b gffkvv }e, mef{ik`}v g`m e}dkz a`nezig}ae` zkw{kv}km }e fezzejezg}k a`nezig}ae` xze~amkm a` }dav gxxlafg}ae` nez fe~kzgbk. Qe{gfc`erlkmbk g`m gbzkk }dg} ngal{zk ez zkn{vgl }e xze~amk }dkvk mef{ik`}v ez a`nezig}ae`, igq jk fg{vk }e zkvfa`m ez fg`fkl qe{z fe~kzgbk.

    1. DA~ ez k`k}af k}a`b Xzedaja}km? e bk`k}af a`nezg}ae`, a`fl{ma`b ngal kmafgl da}ez, g`m `e a`nezg}ae` zklg}km }e DA~}k}a`b de{lm jk xzeamkm Fglanez`ag lgr xzedaja} g` DA~ }k} nze jka`b zkw{azkm ez {km j g dkgl}d a`{zg`fk fexg` ezdkgl}d fgzk kzafk xlg` g g fe`ma}ae` en ej}ga`a`b dkgl}d fekzgbk

    Gll GxxlafG`}V Gbk 74 G`m elmkz i{V} Vab` G`m mG}k }daV GxxlafG}ae` ckkx G fexq en }daV GxxlafG}ae` nez qe{z zkfezm

    A dg~k zk~akrkm gll zkvxe`vkv xkz}ga`a`b }e ik a` }dav gxxlafg}ae`. A dg~k zkgm }dk v{iigzq en jk`kna}v g`m }dk }kziv g`m fe`ma}ae`v en fe~kz)gbk g`m g{}dezag}ae`v vk} nez}d gje~k. Ra}d iq er` vab`g}{zk jkler, A zkxzkvk`} }dg} }dk a`nezig}ae` xze~amkm a` }dav gxxlafg}ae` av feixlk}kg`m gff{zg}k }e }dk jkv} en iq c`erlkmbk, g`m A {`mkzv}g`m g`m gbzkk }e }dk }kziv g`m fe`ma}ae`v en fe~kzgbk g`m }dk g{}dezag}ae`v A dg~kxze~amkm. A gle`k gi zkvxe`vajlk nez }dk gff{zgfq g`m feixlk}k`kvv en }dk a`nezig}ae` xze~amkm e` }dav gxxlafg}ae`. A dg~k xkzve`gllq zk~akrkma`nezig}ae` xze~amkm e` }dav gxxlafg}ae`, k~k` an A mam `e} nall e{} }dk gxxlafg}ae` iqvkln. ]e }dk jkv} en iq c`erlkmbk g`m jklakn, gll a`nezig}aee` }dav gxxlafg}ae`, a`fl{ma`b gll a`nezig}ae` xze~amkm a` }dk ikmafgl dav}ezq vkf}ae` en }dav gxxlafg}ae`, av gff{zg}k, }z{k g`m feixlk}k. A {`mkz)v}g`m }dg} fe~kzgbk igq jk fg`fkllkm ez zkvfa`mkm an l{k Vdaklm mk}kzia`kv }dg} a`nezig}ae` e` }dav gxxlafg}ae` av ig}kzagllq a`gff{zg}k, `e} }z{ez a`feixlk}k, }e }dk kt}k`} xkzia}}km jq gxxlafgjlk lgr. A n{z}dkz {`mkzv}g`m }dg} A i{v} xze~amk l{k Vdaklm ra}d g`q `kr a`nezig}ae` }dg}gzavkv gn}kz }dk v{jiavvae` en }dav gxxlafg}ae` j{} jknezk iq k`zellik`} ra}d l{k Vdaklm jkba`v. $Aixez}g`}? gfd gm{l} gxxlafg`} i{v} xze~amk

    }dkaz er` vab`g}{zk.!

    Vab`g}{zk en gxxlafg`} $ez lkbgl b{gzmag`!

    TUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    ]emgqv mg}k $zkw{azkm!

    UUUUU%UUUUU%UUUUUUUUU

    Xza`} `gik $g`m zklg}ae`vdax an gxxlafg`} av g ia`ez!

    UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    Vab`g}{zk en gxxlafg`}v vxe{vk%meikv}af xgz}`kz $an gxxlqa`b!

    TUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    ]emgqv mg}k $zkw{azkm!

    UUUUU%UUUUU%UUUUUUUUU

    Xza`} `gik

    UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    Vab`g}{zk en ngialq ikijkz gbk 74 g`m e~kz $an gxxlqa`b!

    TUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    ]emgqv mg}k $zkw{azkm!

    UUUUU%UUUUU%UUUUUUUUU

    Xza`} `gik

    UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    Vab`g}{zk en ngialq ikijkz gbk 74 g`m e~kz $an gxxlqa`b!

    TUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    ]emgqv mg}k $zkw{azkm!

    UUUUU%UUUUU%UUUUUUUUU

    Xza`} `gik

    UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    Flafc dkzk }e Gxxlq nez Jl{k Vdaklm en Fglanez`ag E`la`k

    http://www.blueinsuranceshield.com/ca_blueshield_get_a_quote
  • 8/7/2019 Blue Shield of California Individual Family Application C12900-A 1-2011

    9/12F7:188)GK)G $4%78!

    xGz} 77 V}G}kik`} en b{GzG`}kkm aVV{k klabaJala}q an Gxxlqa`b nez G daxGG b{GzG`}kkm)aVV{k xlG`

    An qe{ dg~k g xzk)ktav}a`b fe`ma}ae` g`m gzk fe`fkz`km gje{} ej}ga`a`b dkgl}d fgzk fe~kzgbk, l{k Vdaklm ennkzv g` gl}kz`g}a~k }dg} qe{ igq rg}e fe`vamkz.

    ]dk nkmkzgl Dkgl}d A`v{zg`fk Xez}gjala}q g`m Gffe{`}gjala}q Gf} $DAXGG! igckv a} kgvakz nez xkexlk fe~kzkm {`mkz ktav}a`b bze{x dkgl}d xlg`v }e ig}ga` fe~kzgbk zkbgzmlkvv en xzk)ktav}a`b fe`ma}ae`v rdk` }dkq fdg`bk oejv ez gzk {`kixleqkm nez jzakn xkzaemv en }aik. Mkxk`ma`b e` qe{z zkvxe`}e }dk v}g}kik`}v jkler, qe{ igq jk klabajlk nez b{gzg`}kkm avv{k a` gffezmg`fk ra}d DAXGG, g`m l{k Vdaklm rall g{}eig}afgllq gffkx} qe{z gxxlafg}aenez e`k en a}v b{gzg`}kkm avv{k xlg`v. gfd xkzve` e` }dk gxxlafg}ae` i{v} ikk} DAXGG klabajala}q zkw{azkik`}v }e w{glanq nez g b{gzg`}kkm avv{k x

    An qe{ gzk gxxlqa`b nez fe~kzgbk e` jkdgln en g`q mkxk`mk`}v rde gzk `e} klabajlk nez g b{gzg`}kkm avv{k xlg`, }dkaz fe~kzgbk rall jk v{jokf} }eikmafgl {`mkzrza}a`b, ktfkx} nez fdalmzk` rde rkzk k`zellkm {`mkz g`q xzaez fzkma}gjlk fe~kzgbk ra}da` 68 mgqv en }dk jaz}d ez xlgfkik`} nezgmex}ae`. G mkxk`mk`} fdalm rde av :; qkgzv en gbk ez qe{`bkz ez g mkxk`mk`} vxe{vk gxxlqa`b nez b{gzg`}kkm avv{k i{v} feixlk}k g vkxgzg}V}g}kik`} en B{gzg`}kkm Avv{k labajala}q $l{k Vdaklm rall gffkx} fexakv en }dk V}g}kik`} en B{gzg`}kkm Avv{k labajala}q!. Nez gmma}ae`gl gxxlafg}

    ez f{zzk`} b{gzg`}kkm avv{k zg}kv, xlkgvk fe`}gf} qe{z l{k Vdaklm gbk`} ez fgll l{k Vdaklm g} $488! =67):481.

    V}G}kik`} en b{GzG`}kkm aVV{k klabaJala}q . fdkfclaV} an Gxxlqa`b nez G daxGG b{GzG`}kkm)aVV{k xlG`

    xgv r wvg g v g bgg avv v g j bgg

    avv g g j

    Qkv @e 7. A dg~k dgm g }e}gl en g} lkgv} 74 ie`}dv en dkgl}d fgzk fe~kzgbk $a`fl{ma`b FG ez Fgl)FG, an gxxlafgjlk!

    ra}de{} g lgxvk a` fe~kzgbk en iezk }dg` >6 mgqv $ktfl{ma`b kixleqkz)aixevkm rga}a`b xkzaemv!.

    Qkv @e :. Iq iev} zkfk`} fe~kzgbk rgv }dze{bd g` kixleqkz)vxe vezkm dkgl}d xlg` $FG g`m Fgl)FG gzk fe`vamkzkm

    kixleqkz)vxe`vezkm fe~kzgbk!.

    Qkv @e 6. A gffkx}km g`m ktdg{v}km g`q g~galgjlk FG g`m%ez Fgl)FG fe~kzgbk. $An FG%Fgl)FG rkzk `e} g~galgjlk,

    fdkfc qkv!.

    FG%Fgl)FG fe~kzgbk mg}kv UUU%UUU%UUUUUU }dze{bd UUU%UUU%UUUUU

    FG Gmia`av}zg}ez UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU ]klkxde`k UUUUUUUUUUUUUUUUU

    A`v{zg`fk Fgzzakz UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU ]klkxde`k UUUUUUUUUUUUUUUUU

    An qe{z iev} zkfk`} fe~kzgbk rgv kixleqkz)vxe`vezkm g`m qe{ rkzk `e} klabajlk nez FG g`m%ez Fgl)FG

    fe~kzgbk, xlkgvk ktxlga`? UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    Qkv @e =. A gi f{zzk`}lq klabajlk nez fe~kzgbk {`mkz g bze{x ez kixleqkz vxe`vezkm dkgl}d xlg`, Ikmafgzk ez Ikmafgam.

    Qkv @e ;. Iq iev} zkfk`} fe~kzgbk }kzia`g}km jkfg{vk en `e`xgqik`} en m{kv%xzkia{i ez nzg{m.

    a gvrv vgv 7, : . 6 g v, g gvrv vgv = . ; g , gv g vv j g g gg vv g

    b{GzG`}kkm aVV{k fe~kzGbk ex}ae`V $xlkGVk Vklkf} e`k!

    G. An qe{ c`er }dg} qe{ rall `e} w{glanq nez fe~kzgbk, ez me `e} rg`} }e gxxlq nez g` {`mkzrza}}k` xlg`, fdkfc }dav jet?

    Avv{k }dk B{gzg`}kkm Avv{k Xlg` e`lq. Va`fk A dg~k fdevk` }dav ex}ae`, A {`mkzv}g`m }dg} A rall `e} jk fe`vamkzkm nez g` {`mkzrza}}k` xlg`

    J An qe{ gzk gxxlqa`b nez je}d B{gzg`}kkm Avv{k g`m g` {`mkzrza}}k` xlg`, vklkf} e`k en }dk nellera`b?

    B{gzg`}kkm Avv{k fe~kzgbk g} }dk kgzlakv} knnkf}a~k mg}k, ve }dg} A gi fe~kzkm m{za`b }dk {`mkzrza}a`b xzefkvv en }dk a`ma~am{gl xlg`.

    $A {`mkzv}g`m }dg} an iq gxxlafg}ae` nez }dk {`mkzrza}}k` xlg` av gxxze~km, A rall g{}eig}afgllq jk }zg`vnkzzkm }e }dk {`mkzrza}}k` xlg`.

    An a} av `e} gxxze~km, A rall fe`}a`{k }e zkfka~k B{gzg`}kkm Avv{k.!

    Avv{k }dk B{gzg`}kkm Avv{k xlg` e`lq an A gi `e} gxxze~km nez }dk {`mkzrza}}k` xlg`. $A {`mkzv}g`m }dg} A rall `e} dg~k g`q fe~kzgbk {`}al

    iq gxxlafg}ae` nez }dk {`mkzrza}}k` xlg` av xzefkvvkm g`m ka}dkz gxxze~km ez mkfla`km.!

    b{GzG`}kkm aVV{k xlG` ex}ae`V $xlkGVk Vklkf} e`k!

    Gffkvv# DI xgfcgbk Vdaklm Vg~a`bv =888/

    Vdaklm Vxkf}z{i XX ;;88 Vdaklm Vxkf}z{i XX ;888/

    Gffkvv# ^gl{k DI

    q vab`a`b }dav v}g}kik`} A ~kzanq }dg} A dg~k zkgm g`m {`mkzv}eem }dk klabajala}q fe`ma}ae`v lav}km gje~k g`m }dg} gll en

    }dk a`nezig}ae` av }z{k g`m fezzkf}.

    Vab`g}{zk en gxxlafg`} ez lkbgl b{gzmag` ]emgqv mg}k $zkw{azkm! Xza`} `gik

    T UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU UUUUU%UUUUU%UUUUUUUUUUUU UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    Gxxlafg`}v Vefagl Vkf{za}q @{ijkUUUUU UUUUU UUUUU ) UUUUU UUUUU ) UUUUU UUUUU UUUUU

    /[`mkzrza}}k` jq Jl{k Vdaklm en Fglanez`ag Lank Dkgl}d A`v{zg`fk Feixg`q.

    Flafc dkzk }e Gxxlq nez Jl{k Vdaklm en Fglanez`ag E`la`k

    http://www.blueinsuranceshield.com/ca_blueshield_get_a_quote
  • 8/7/2019 Blue Shield of California Individual Family Application C12900-A 1-2011

    10/12F7:188)GK)G $4%78!

    xGz} 7: xzem{fkz a`neziG}ae` iv j j x

    7. Mam qe{ feixlk}k }dav gxxlafg}ae`5 fQkv f@e

    :. An qkv, mam qe{ gvc kgfd w{kv}ae` a` }dav gxxlafg}ae` ktgf}lq gv vk} nez}d5 fQkv f@e

    6. Gzk }dk g`vrkzv zkfezmkm ktgf}lq gv ba~k` }e qe{5 fQkv f@e, g}}gfd ktxlg`g}ae`.

    =. Mam qe{ vkk }dk gxxlafg`}5 fQkv f@e

    ;. Gzk qe{ grgzk en g`q a`nezig}ae` `e} mavflevkm a` }dav gxxlafg}ae` en dkgl}d, rdafd igq dg~k g jkgza`b e` }dav zavc5fQkv, g}}gfd ktxlg`g}ae` f@e

    >. k~akr g`m vklkf} e`k en }dk nellera`b?

    f A mam `e} gvvav} }dk gxxlafg`} a` g`q rgq a` feixlk}a`b ez v{jia}}a`b }dav gxxlafg}ae`. Gll a`nezig}ae` rgv feixlk}km jq }dk gxxlafg`} ra}dgvvav}g`fk ez gm~afk en g`q ca`m nzei ik.

    f A gvvav}km }dk gxxlafg`} a` v{jia}}a`b }dav gxxlafg}ae`. Gll a`nezig}ae` a` }dk dkgl}d w{kv}ae``gazk rgv xze~amkm jq }dki. A gm~avkm }dkgxxlafg`} }dg} }dkq vde{lm g`vrkz gll w{kv}ae`v feixlk}klq g`m }z{}dn{llq g`m }dg} `e a`nezig}ae` zkw{kv}km e` }dk gxxlafg}ae` vde{lm jkra}ddklm. A ktxlga`km }dg}, an a`nezig}ae` av ra}ddklm, }dg} fe{lm zkv{l} a` }dkaz fe~kzgbk jka`b fg`fkllkm lg}kz. ]dk gxxlafg`} a`mafg}km }e i}dg} }dkq {`mkzv}eem }dkvk a`v}z{f}ae`v g`m rgz`a`bv. ]e }dk jkv} en iq c`erlkmbk, }dk a`nezig}ae` e` }dk gxxlafg}ae` av feixlk}k g`mgff{zg}k. A {`mkzv}g`m }dg}, an g`q xez}ae` en }dav v}g}kik`} jq ik av nglvk, A igq jk v{jokf} }e fa~al xk`gl}akv en {x }e -78,888.

    2. Me qe{ rg`} }dk vkz~afk gbzkkik`}%xelafq vk`} mazkf}lq }e }dk v{jvfzajkz5 fQkv f@e

    Xzem{fkz `{ijkz?

    UUUUU UUUUU UUUUU UUUUU UUUUU UUUUU UUUUU UUUUU UUUUU

    ]klkxde`k `{ijkz?

    $ !

    f[xmg}k

    Ngt `{ijkz?

    $ !

    f[xmg}k

    Xzem{fkz `gik?

    igal Gmmzkvv? f[xmg}k

    Xzem{fkz gmmzkvv?

    f[xmg}k

    Fa}q V}g}k _AX Femk

    V{xkz xzem{fkz gik? V{xkz xzem{fkz {ijkz

    UUUUU UUUUU UUUUU UUUUU UUUUU UUUUU UUUUU UUUUU UUUUU

    }gv g $w! x vg$w! x g

    UUUUU%UUUUU%UUUUUUUUUUUU TUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU

    EAF? xgv v g g gg v a vv g J V

    g g gg jg g anx Ggv g j gt ) := v g g, 2 gv

    g r, $444! 64>)6=:8

    Gxxlafg`}v Vefagl Vkf{za}q @{ijkUUUUU UUUUU UUUUU ) UUUUU UUUUU ) UUUUU UUUUU UUUUU

    )

    4 7 8 > 2 : 8 8 : 488 ;>177;> 488 62>)=286

    D K G L ] D F E ^ K Z G B K A @ V [ Z G @ F K V K Z ^ A F K V

    m k ` ` a v g H d f a v a ` f . f e i

    X e J e t 1 = 7 2

    V g ` } g Z e v g F G 1 ; = 8 ;

    Flafc dkzk }e Gxxlq nez Jl{k Vdaklm en Fglanez`ag E`la`k

    http://www.blueinsuranceshield.com/ca_blueshield_get_a_quote
  • 8/7/2019 Blue Shield of California Individual Family Application C12900-A 1-2011

    11/12F7:188)GK)G $4%78!

    knezk qe{ vk`m a` qe{z gxxlafg}ae` nez

    xzefkvva`b, rk v{bbkv} qe{ be }dze{bd

    }dav fdkfclav}. Igck v{zk kgfd jet av

    fdkfckm enn ve }dg} qe{z gxxlafg}ae` av

    xzefkvvkm gv w{afclq gv xevvajlk.

    Igck v{zk qe{ g`m kgfd gxxlqa`b ngialq

    ikijkz dg~k?

    G`vrkzkm k~kzq w{kv}ae`, k~k` an qe{ gzk

    `e} v{zk a} gxxlakv }e qe{.

    Xza`}km flkgzlq a` jl{k ez jlgfc a`c.

    Vklkf}km g Xkzve`gl Xdqvafag` e`lq an

    qe{ gzk gxxlqa`b nez Gffkvv# DI ez

    Gffkvv# ^gl{k DI3 vklkf}km g Mk`}gl

    xze~amkz e`lq an qe{ gzk gxxlqa`b nez

    Mk`}gl DI.

    A`mafg}km qe{z xgqik`} ex}ae` a` Xgz} 7

    en }dk gxxlafg}ae`. An qe{ fdevk fzkma}

    fgzm xgqik`}v ez gvq-Xgq, qe{ i{v}

    feixlk}k }dk g{}dezag}ae` nezi e`

    }dk zk~kzvk vamk en }dav xgbk g`m vk`m

    a} a` rdk` qe{ v{jia} qe{z gxxlafg}ae`

    }e l{k Vdaklm.

    V}gxlkm g xkzve`gl fdkfc ez ie`kq ezmkz

    }e qe{z gxxlafg}ae` a` g` gie{`} kw{gl

    }e }dk m{kv%xzkia{iv nez }dk nazv} ie`}d

    en fe~kzgbk.

    Vab`km Xgz} 1 g`m 78 en }dk gxxlafg}ae`.

    Vab`g}{zkv jq gll gxxlafg`}v $gbk 74

    g`m e~kz! gzk zkw{azkm.

    k}{z`km }dk gxxlafg}ae` ra}da` 68 mgqv

    en qe{z mg}k g`m vab`g}{zk.

    Gxxlafg}ae` Fdkfclav}

    [va`b }dk zg}k jeec xze~amkm }e qe{,

    fglf{lg}k qe{z zg}kv ez }glc }e qe{z gbk`}

    }e bk} kv}aig}km zg}kv. Qe{ igq zkfka~k

    zg}kv dabdkz }dg` qe{z gbk`} w{e}km qe{

    jgvkm e` [`mkzrza}a`b mk}kzia`g}ae .

    Nez }dk nazv} ie`}dv m{kv%xzkia{i

    v}gxlk g xkzve`gl fdkfc ez ie`kq ezmkz

    }e qe{z gxxlafg}ae` a` g` gie{`} kw{gl}e }dk m{kv%xzkia{iv nez nez e`k ie`}d,

    xgqgjlk }e l{k Vdaklm. An xgqa`b nazv}

    ie`}dv m{kv%xzkia{i jq fzkma} fgzm

    xlkgvk nall e{} }dk zkw{azkm a`nezig}ae`

    e` Xgbk 7:.

    Xgk`} Ex}ae`

    V{jvkw{k`} m{kv%xzkia{iv i{v} jk

    xgam a` gm~g`fk. l{k Vdaklm ennkzv ne{z

    xgqik`} ik}demv. Xlkgvk vklkf} g jalla`bex}ae` jkler?

    7. gvq-Xgq Ie`}dlq Xgqik`} ie`}dlq

    xgqik`}v gzk dg`mlkm g{}eig}afgllq,

    ~ag klkf}ze`af }zg`vnkz nzei qe{z

    fdkfca`b ez vg~a`bv gffe{`}.

    :. Fzkma} Fgzm Xgqik`} ie`}dlq%

    w{gz}kzlq $vklkf} nzkw{k`fq e`

    nellera`b xgbk! xgqik`}v gzk

    dg`mlkm g{}eig}afgllq, ~ag klkf}ze`af

    fdgzba`b }e qe{z fzkma} fgzm.

    6. Ie`}dlq $68 mgqv! mazkf} jalla`b

    =. W{gz}kzlq $18 mgqv! mazkf} jalla`b

    g-Xg g`m Fzkma} Fgzm

    Xgk`} Ex}ae`

    } v Gg xgv?

    Feixlk}k }dk g{}dezag}ae` nezi e`}dk `kt} xgbk g`m zk}{z` a} ra}d qe{z

    gxxlafg}ae`. An qe{ dg~k vklkf}km gvq-Xgq

    gv qe{z xgqik`} ex}ae` xlkgvk v}gxlk g

    mkxeva} vlax ez jlg`c fdkfc igzckm ^AM

    }e qe{z g{}dezag}ae` nezi g

    g v%v . An

    qe{ xzknkz `e} }e g}}gfd g ~eamkm fdkfc ez

    mkxeva} vlax, qe{ i{v} xze~amk }dk ze{}a`b%

    }zg`va} `{ijkz en qe{z na`g`fagl a`v}a}{}ae`.

    Jalla`b A`neig}ae`

    Qe{ gzk klabajlk nez g`q A`ma~am{gl NgialqDkgl}d Xlg` an qe{? gzk g Fglanez`ag zkvamk`},

    gzk a`klabajlk nez Ikmafgzk, g`m gzk `e}

    gbk >; ez e~kz.

    An qe{z gxxlafg}ae` av gxxze~km, qe{ igq

    jk klabajlk }e zkfka~k Gffkvv# DI ez

    Gffkvv# ^gl{k DI jk`kna}v e` }dk nazv} en

    }dk ie`}d nellera`b l{k Vdaklmv gxxze~gl

    mg}k, g`m e` g`q mgq en }dk ie`}d, ktfkx}

    nez }dk :1}d, 68}d ez 67v} en }dk ie`}d

    nellera`b l{k Vdaklmv gxxze~gl mg}k nez

    g`q ANX XX Xlg`.

    Qe{z vxe{vk ez Meikv}af Xgz}`kz ${`mkz gbk>;! g`m mkxk`mk`} fdalmzk` {`mkz gbk :>,

    gzk klabajlk }e gxxlq nez mkxk`mk`} fe~kzgbk.

    Fgll l{k Vdaklm g} $488! 6;7):=>; ez }glc }e

    qe{z gbk`} }e na`m e{} rdafd ex}ae` av jkv}

    nez qe{.

    xvv G J V zgv xvg ag ev?

    An qe{ re{lm lack }e g{}dezak qe{z vxe{vk,

    meikv}af xgz}`kz ez g }dazm xgz}q }e gffkvv

    qe{z xkzve`gl dkgl}d a`nezig}ae`, xlkgvk

    feixlk}k }dk nezi }a}lkmG{}deazg}ae`

    ne Jl{k Vdaklm }e Mavflevk Xkve`gl . Dkgl}d

    A`neig}ae` }e g ]dam Xg}q. ]e ej}ga`

    }dav nezi be }e jvg

    ez fgll $488! =67):481.

    Bk`kgl A`neig}ae`

    Flafc dkzk }e Gxxlq nez Jl{k Vdakln en Fglanez`ag E`la`k

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  • 8/7/2019 Blue Shield of California Individual Family Application C12900-A 1-2011

    12/12

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    Gz} G $f %vgv g jv !

    mg $fdeevk e`k!? DIE g`m Mk`}gl DIE V{jvfzajkzv i{v} {vk 7v} en ie`}d. f 7v} en ie`}d, ez f 7;}d en ie`}d`c ze{}a`b%}zg`vnkz {ijkz Jg`c gffe{`} {ijkz

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    }dezag}ae` g`m Vab`g}{zk$v!}eig}af Xgqik`} jq mkja} nzei fdkfca`b%vg~a`bv gffe{`}?}dezak iq xlg , Jl{k Vdaklm en Fglanez ag ez Jl{k Vdaklm en Fglanez ag Lank Dkgl}d A v{zg`fk Feixg`q $Jl{k Vdaklm!, }e a a}ag}k mkja}v $g`m%ez igck fezzkf}ae`v }e xzk~ae{v mkja}v, gv `kfkvvgzq! }e }dk jg`c gffe{ } amk }anakm e }dav nezi e`xgqik } mg}k $ez ra}da 7 }e : mgqv jknezk ez gn}kz }dk xgqik } mg}k! g`m ra}d }dk nzkw{k`fq vk} nez}d gje~k nez }dk x{zxevk en xgqik } en }dk ie }dlq m{kv%xzkia{i erkm nez iqvkln g`m g`q ngialq ikijkzv fe~kzkm jq Jl{k Vdaklm. A glveezak iq na g`fagl a v}a}{}ae }e zkm{fk }dk jglg`fk en iq gffe{ } jq }dk gie{ } en v{fd mkja}v $g`m%ez fezzkf}ae`v }e xzk~ae{v mkja}v!. A rall iga }ga v{nnafak } fellkf}km n{`mv a iq gffe{ } nez }dk n{ll gie{ } en kgfd xgqik }. An }dk g{}eig}af} }zg`vgf}ae k~kz ngalv $k.b., `e n{`mv gzk g~galgjlk!, Jl{k Vdaklm rall igal g jall }e ik g} iq gmmzkvv e zkfezm g`m A rall jk zkvxe`vajlk nez igca b iq xgqik } jq fdkfc ez ie`kq ezmkz, gle`b ra}d g zk}{z a}ki vkz~afk fdgzbk.}eig}af Xgqik`} jq fzkma} fgzm?}dezak iq xlg , Jl{k Vdaklm en Fglanez ag ez Jl{k Vdaklm en Fglanez ag Lank Dkgl}d A v{zg`fk Feixg`q $Jl{k Vdaklm!, }e fdgzbk $g`m%ez gxxlq fzkma}v, an fezzkf}a b kzzezv }e xzk~ae{v fdgzbkv! }dk fzkma} fgzm amk }anakm e }dav nezi e }dk xgqik }$ez ra}da 7 }e : mgqv jknezk ez gn}kz }dk xgqik } mg}k! g`m ra}d }dk nzkw{k`fq vk} nez}d gje~k nez }dk x{zxevk en xgqik } en }dk ie }dlq m{kv%xzkia{i erkm nez iqvkln g`m g`q ngialq ikijkzv fe~kzkm jq Jl{k Vdaklm. An }dk fzkma} fgzm

    vgf}ae k~kz ngalv $k.b., e~kz laia}, ktxazkm!, Jl{k Vdaklm rall igal g jall }e ik }e iq gmmzkvv e zkfezm g`m A rall jk zkvxe`vajlk nez igca b iq xgqik } jq fdkfc ez ie`kq ezmkz.ma}ae`gl a`nezig}ae` an xgqa`b nazv} ie`}dv m{kv%xzkia{i e`lq jq fzkma} fgzm?

    lq }dk nazv} ie }dv m{kv%xzkia{i jet av fdkfckm, }dav g{}dezag}ae av e lq ~glam }e fdgzbk }dk nazv} ie }dv m{kv%xzkia{i erkm }e Jl{k Vdaklm. A {`mkzv}g`m iq fzkma} fgzm rall jk fdgzbkm nez }dk kv}aig}km nazv} ie }dv m{kv%xzkia{i aiikmag}k zkfkax} en iq gxxlafg}ae 3 derk~kz, }dav xgqik } mekv `e} fe`v}a}{}k gxxze~gl en iq gxxlafg}ae , g`m an iq gxxlafg}ae av gffkx}km, g mannkzk } zg}k igq gxxlq. An A gi gffkx}km g} g mannkzk } zg}k, }dk mannkzk`fk a m{kv%xzkia{i i{v} jk xgam xzae

    dk ezaba gl knnkf}a~k mg}k en fe~kzgbk. Jl{k Vdaklm rall `e} g{}eig}afgllq fdgzbk }dk mannkzk`fk a zg}k erkm }e }dk fzkma} fgzm ra}de{} g vkxgzg}k g{}dezag}ae nzei }dk v{jvfzajkz.}afk }e fdg`bk%fg`fkl zkw{azkm?l fe }a {k }e jk mkja}km%fdgzbkm }dk gie{ } en m{kv%xzkia{i erkm { }al A fg`fkl }dav G{}eig}af Xgqik } g{}dezag}ae {xe g} lkgv} 78 fglk`mgz mgqv `e}afk jknezk g mkja}%fdgzbk av }e eff{z. ]e fg`fkl }dav g{}eig}af xgqik } g{}dezag}ae , ez ak gzk fdg`bkv }e iq gffe{ } jka b mkja}km%fdgzbkm, A i{v} fe }gf} F{v}eikz Vkz~afk g} $488! =67):481. Jl{k Vdaklm igq fg`fkl }dav g{}dezag}ae g} g`q }aik {xe `e}afk }e ik.ab a b jkler, A gbzkk }e }dk }kziv g`m fe`ma}ae`v en }dav g{}dezag}ae nezi $an }dk jg`c gffe{ } av g oea } gffe{ }, gll gffe{ }delmkzv i{v} vab ! g`m A gfc`erlkmbk }dg} A dg~k zkfka~km g fexq en }dav nezi. A gfc`erlkmbk }dg} gll xgqik }vgf}ae`v i{v} feixlq ra}d }dk xze~avae`v en [.V. lgr. A rall igck xgqik }v jq fdkfc ez ie`kq ezmkz { }al iq g{}eig}af xgqik } vkz~afk dgv jkk gf}a~g}km.

    `g}{zk Mg}k Vab`g}{zk Mg}k

    `} `gik Zklg}ae`vdax Xza`} `gik Zklg}ae`vdax

    )

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    )

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