Application for Individual Health Benefits Plan — Individuals and Families - Direct Access, HMO and EPO Plans (744)

If you would like to receive a quote or enroll in any Basic or Traditional Indemnity Plan, please contact our Sales Department at 1-800-224-1234.

Please click on the link above to download a Horizon BCBSNJ Individual application. You will need Adobe® Acrobat® Reader™ in order to print this document. If you do not have Adobe® Acrobat®, please click on the link below to download it free.

After printing the application, please fill it out completely and mail to:

Horizon BCBSNJ
PO BOX 1330
Newark, NJ 07101-9845

IMPORTANT: If you had prior coverage, please submit a copy of your most recent Certificate of Creditable Coverage (COCC). The COCC can be obtained from your prior health insurance carrier.

• Please note for HMO plans the effective date of coverage must be the 1st or the 15th of the month.
• Payment for your first month’s premium must be included with your application.
• For those customers who wish to pay their premium by credit card with Visa or MasterCard, please note that this payment will be accepted for the initial premium payment only. You will be billed separately for all billing periods after the initial monthly premium.
• Please submit Student verification for any dependents over the age of 19.
• If the last name of your spouse or civil union partner is different, please submit a copy of the marriage license or civil union license/certificate.
• If you change your billing cycle (e.g., from quarterly to monthly) when you change your coverage, the new payment plan will become effective on your next billing cycle, not on the date of conversion. Your present bill must be paid before the change is made.
• You can receive credit for any deductible satisfied under your previous coverage if the deductible amount was satisfied within the same calendar year that your coverage started, provided that there was not a lapse in coverage. This credit will be applied whether or not your coverage was with Horizon Blue Cross Blue Shield of New Jersey or another carrier.
• Generally, the effective date of your coverage shall be no later than the first of the month following the month in which the completed application was dated and the premium payment received. However, with respect to applications submitted during the November Open Enrollment Period by persons who are eligible for Group Coverage and wish to enroll in an Individual Health Benefits Plan, or persons who wish to replace their current Individual Health Benefits Plan with a more comprehensive Individual Health Benefits Plan, the effective date of coverage shall be January 1 of the following year.
• With all of these products, you can choose from over 27,000 doctors and specialists in our network. Our Direct Access products also allow you to see any other doctor, specialist or hospital outside the network.
• If you need any additional assistance completing this application, please call 1-800-224-1234 to speak with a Horizon BCBSNJ Sales Representative.