Can you provide me the Application Form for Dental and Vision Non-Group Enrolment/ Change Request of Horizon Blue Cross Blue Shield of New Jersey?

Horizon Blue Cross Blue Shield of New Jersey is the only licensed Blue Cross and Blue Shield Association plan in New Jersey, providing health insurance coverage to over 3.2 million people throughout all of New Jersey.


The Application Form for Dental and Vision Non-Group Enrolment/ Change Request of Horizon Blue Cross Blue Shield of New Jersey is as follows:







Few Things that are to be mentioned in the Form


A. Type of Activity to be completed by Applicant Refer to instructions before completing this form. (Check all that apply)

1. ADD Date of Event Reason
Enrolment of a new Subscriber
Add Spouse
Add Civil Union Partner

2. REMOVE Date of Event Reason
Remove Spouse
Remove Civil Union Partner

3. Other CHANGE Date of Event Reason
Name Change
Change Plan
Other

B. Plan Options Please select desired plan(s) and unit(s) of coverage

Pediatric Dental and Family Pediatric Dental (check one)
Horizon Young Grins Stand Alone Pediatric Dental (SAPD) (only provides benefits for dependents under age 19)
Horizon Family Grins
Horizon Family Grins Plus