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For your own protection, you, the applicant,
must complete the application. You are solely
responsible for its accuracy and completeness.
All information must be stated accurately.
All questions must be answered in full or the
application may be returned to you and may result
in a delay in processing.
For additional information or explanations,
attach additional sheets if necessary. All attachments
must be signed and dated.
This application must be completed and signed
in blue or black ink. Sign and date Part 8 of
the application. Signatures are required for
all applicants, including your spouse and dependents
age 18 and older.
This application must be received within 30
days from signature date.
Even if the application is approved, any misstatements
or omissions may result in future claims being
denied and the plan being voided from the beginning.
Your insurance will become effective only if
this application is approved as applied for,
the appropriate premium is enclosed, and other
specific conditions are met.
Please return this application and your check
to Make Check payable to "Blue Cross of
California" or " Blue Shield of California")
Include your check or money order made payable
to "Blue Cross of California" , "
Blue Shield of California" ."PacifiCare"
If you have any questions please call us at
(818) 654-4548
Provider
Finder
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Colorado 
