Blue Cross and Blue Shield of Florida

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Group Product Information Request Form

Thank you for your interest in Blue Cross and Blue Shield of Florida products and services. If you have not already done so, please visit our Products, Plans and Services section. It includes detailed product descriptions and information that may be helpful as you search for coverage options.

Should you prefer to receive product information, please complete the Information Request Form below and click the Submit button. You should receive the product information requested through the mail within ten business days.

Name:
Name of Business:
Business Address:
Suite No./Address Line 2:
City:
State:
Zip Code:
32000-1212
Email Address:
example@aol.com
Re-enter Email Address:
Please check here if you would like to receive promotional information from Blue Cross and Blue Shield of Florida via e-mail.
Business Phone Number:
904-555-1212
Business Phone Extension:
Fax Number:
904-555-1212
Number of Full Time Employees
(25 or more hours a week):
Do You Currently Offer Group Health Insurance:
Present Insurance Anniversary Month:
Employer Contribution Percentage:


What Product(s) Are You Interested In?
Group 1-99
HMO
PPO
Multiple Health Product Offerings (Dual)
Group 100+
HMO
PPO
Multiple Health Product Offerings (Dual)
Other Group Products
Dental
Life
Accidental Death & Dismemberment (AD&D)
Short & Long Term Disability
Health Reimbursement Account
Flexible Spending Account

How did you hear about our website?
(Please select one)
    Through an advertisement you received in the mail
      Please enter the 5 character reference code found in the bottom right-hand corner of the business reply card.
    Through a newspaper advertisement
      Please enter the 4 digit number found in the bottom right-hand corner of the advertisement or request for information card.
      A
    Through a television commercial

    Through the Florida Blue E-Newsletter

    While surfing the internet

    Through a friend

    Through a family member

    Through a Blue Cross and Blue Shield of Florida Employee

    Through an online agent

    Other

 
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