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Supply Requisition Form by iyn12404


Supply Requisition Form document sample

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									                                                                                     Individual/65+ Products
                                                                                      Supply Requisition Form
      Name: ________________________ Agent # _______ Date: _______

      Address __________________________________ Phone #___________

      Please fax your request to: Local 404-923-3100 or Toll Free 1-866-215-4880
      Email to:

QTY                               Item                                QTY                                     Item
       INDIVIDUAL MATERIALS                                                   Misc. Materials
       Brochures – Medical                                                    PPO Directory (E-ACT-003141)
       Combined Blue Value PPO Plans for Individuals (10099)                  6 X 9 Pre-addressed Envelopes (9837)
       Right Plan PPO (0010133)                                               Authorization for Use or Disclosure of PHI
       High Deductible Health Plans for Individuals (HSA                      Indiv. Supply Request Form (50624)
       Compatible) (7706)
       BlueChoice PPO High Deductible Health Plan (10570)
       Flex Plus Brochure (10586)                                             SENIOR MATERIALS
       Blue Vision Individual Sales Slick (SS006)                             Fulfillment Kits
       HSA Overview Brochure (10569)                                          65Plus (Includes: Outline of Medicare Supplement Plans, Smart
                                                                              Choice & Benefit Summaries) (F-1681.089-478)
       HDHP Broker Guide (10570)                                              More Coverage for Less (F-1681.089-481)
       HSA Member Overview Brochure (10579)                                   SmartChoice Form (F-1681.89-450)
       Short Term Medical Brochure w/Appl (10587)                             Smart Choice Rate Sheet (10591)
       Brochures – Dental                                                     Forms
       Individual & Family Dental/includes application & rate                 65Plus Application (Includes Replacement Form and Bank Draft
       sheet (11076)                                                          Form) (F-1681.089-019)
       Rate Sheets                                                            65Plus Rate Sheet (9954)
       PPO Plans (includes new Blue Value & Blue Value Select                 65 Plus Medicare Supplement Change Form (50722)
       rates for all areas) (9947)
       Flex Plus Rate Sheets (9953)                                           Brochures – Other
       HDHP Rate 1,2,3 (9949)                                                 Senior Dental (includes application & rate sheet (11077)
       Right Plan – All rates (9948)                                          Silver Sneakers Guest Pass (9963)
       Individual Term Life Application (10574)                               Silver Sneakers Broker Flyer (F-1681.089-461)
       BlueVision Individual Low Option (INDIV02)                             Silver Sneakers Newsletter (10585)
       Blue Vision Individual High Option(INDIV01)                            Precision Discount Flyer (10568)
       Blue Vision (2-50) Low Option Plan 8014VZ (SG0014)                     Misc. Materials
       Blue Vision (2-50) Voluntary Low Option Plan 8014VV                    Dental Directory (E-AAR-003219)
       Blue Vision (2-50) High Option Plan 8000VZ (SG0013)                    65 Plus #9 Business Reply Envelope, Marketing (F-AAO-001762)
       Blue Vision (2-50) Voluntary High Option Plan 8000VV                   65 plus Pre-addressed Return Envelope (50570)
       Forms                                                                  Bank Draft (G-AAO-001765)
       Individual Product Enrollment Application (includes Bank
       Draft Agreement & Conditioned Authorization Form) (F-
       Individual Products Change Request (A-17-AAE-000636)
       Certification of Dependency Form (A-07-AAE-001821)
       Individual HSA Application (10551)

      For additional information and/or assistance, please call the Broker Helpline at 1-866-215-4879.
      An Independent Licensee of Blue Cross Blue Shield Association
                                                                                                         Rev. 2-15-05 50624

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