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.   

Employer groups and/or producers can use our combination Member Enrollment/Change Guide to enroll new members for coverage or change the status of a current member. This guide includes legally required notices that must be received by the enrolling member before he or she completes the enrollment form. As group leader and/or producer, you are responsible for ensuring the enrolling member receives these notices.

PLEASE NOTE: The enrollment guide is for use only by employer groups and/or producers. Only enrollment forms received from group leaders or producers will be processed. No enrollment forms may be submitted directly by any individual member to Blue Cross and Blue Shield of Louisiana; HMO Louisiana, Inc.; Southern National Life Company, Inc.; or Employee's Choice Voluntary Plans.**  

Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc.
Application for Group Coverage [01MK2732 02/07]* [PDF]

Blue Cross Medical Guide Questionnaire [01MK1763 R0104]* [PDF]

Group Administration Manual [01MK2980 R0507]* [PDF]
  
Inscripción Del Empleado/Formulario Para Cambios Del Empleado [01MK2703S 02/07]* [PDF]
  
Member Enrollment/Change Form [01MK2703 0207] [Use Only for Changes]* [PDF]
 
Member Enrollment/Change Guide [01MK2822 0207] [Use for New Enrollments]* [PDF]

Southern National Life Insurance Company, Inc.
Long Term Disability Underwritten Application [28XX1099 R0595] [PDF]

Master Application for Group Long Term Disability [28XX1064 R1001] [PDF]
 

Employee’s Choice Voluntary
AD&D Employer Application [28XX1376 R0606] [PDF]
 
Change of Status [28XX1385 R0506] [PDF]
 
Employer Application - Voluntary Disability [28XX1429 R0806] [PDF]
 
Employer Application - Voluntary Group Term Life, Dependent Life and AD&D [28XX1459 R0506] [PDF]
 
Voluntary Group Dental Employer's Application [28XX1355 R05/06] [PDF]
 
Vol. Large Group Ins. Employee Enrollment [28XX1357 R08/06] [PDF]
 
Vol. Small Group Dental Employee Enrollment [28XX1475 05/06] [PDF]

View and print other commonly used employer forms.

* Form is used by Blue Cross and Blue Shield of Louisiana, HMO Louisiana, Inc. and Southern National Life Insurance Company, Inc. 
**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.