Below are some of the most commonly used forms. Our forms are updated regularly. Please use the most current form to avoid delays in processing. Read each form carefully for special instructions and/or submission information. HMO Louisiana, Inc. and Southern National Life Insurance Company, Inc. are subsidiaries of Blue Cross and Blue Shield of Louisiana. Employee's Choice Voluntary Plans are offered through Southern National Life Insurance Company, Inc.
Other Commonly Used Forms
Application for Group Life Insurance Proceeds [28XX1002 R1104] [PDF]
Authorized Delegate [23XX7434 R0508] [PDF]
Cobra Continuation of Group Coverage - HMO Louisiana [03100 00081 0597R] [PDF]
Continuation of Group Coverage - Blue Cross [23XX0500 R3/98] [PDF]
Continuation of Group Coverage - HMO Louisiana [03100 0083 0397R] [PDF]
Coverage Cancellation [23XX3160 R0308] [PDF]
Dental Claim [23XX0609 R0304] [PDF]
Dependent Certification [24XX0205 R05/04] [student since age 21] [PDF]
Dependent Certification [24XX0205.1 R05/04] [student since age 19] [PDF]
Employee's Choice Dependent Certification [28XX1419 R0506] [PDF]
Employee's Choice Section 125/Flexible Benefit [28XX1412 R0506] [PDF]
Group Leader Authorized Representative [01MK2807 1106] [PDF]
List Bill Disclosure Statement [23XX7479 R0705] [PDF]
Payment Entity Change Form [01MK2592 R08/06] [PDF]
Producer of Record Change Letter [01MK1940 R0108] [PDF]
