Paper Application How to help your customers apply

Applicants should complete the application included in the enrollment kit. This must be done in black ink.
Applicants should complete all sections of the application and be sure to include dates and relevant details for medical conditions, medications, and physician visits for all persons being covered.
Applicants must read, sign, and date the Declarations and Conditions of Enrollment section of the application.
Be sure to fill out Section O of the application with applicable broker information.
Applicants must read, sign, and date the Authorization for Release of Medical Information.
Applicants applying to waive the preexisting condition clause through a Blue-to-Blue transfer or other creditable coverage must complete all parts of Section G (Other Insurance) and submit a Certificate of Creditable Coverage for each qualifying individual to be covered by the plan.
Print out and carefully read the How to Apply flyer.
Applications should be mailed to Independence Blue Cross using the postage-paid enveloped provided. If using your own envelope, please address it to: