Any change will deem the application void. Enter the employee's social security number, last name, first name, and middle initial. Enter the employee's sex relation. For retroactive enrollment requests Blue Cross and Blue Shield of North Carolina must be notified within 30 days of the change. Any changes received after 30 days will be made effective the first day of the next month's billing period.
Special approvals are necessary for retro-enrollments beyond the designated times.
The Rejection of Coverage section of the application is completed when an employee or any of their dependents are rejecting coverage under the group health care benefit plan, sponsored by the group. If YES is indicated for either of the rejection questions, the entire section must be completed along with Section 9 - Other Insurance Information. In most cases, the group will sponsor only the benefit plans enrolled by the group. Check the applicable box. A description of each contact type can be found in the Section II - Eligibility.