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To see prices for plans in your area, please provide the following information:

1. How did you hear about us?
2. Are you eligible for Medicare Disability? *
Yes

No

If you are eligible for Medicare by reason of disability or End Stage Renal Disease, you must select and apply for a Medicare Eligible plan over the phone. Please call a representative at 1-877-465-1125 (TTY: 711) between 8:00 a.m. – 8:00 p.m. Monday - Friday, and 9:00 a.m. – 5:30 p.m. Saturday, closed Sunday (EST).
3. Effective Date(mm/dd/yyyy)? *
4. Enter your information below; be sure to add all dependents
A dependent can be a spouse, domestic partner (if applicable), and/or eligible child, (by birth, adoption or legal guardianship).
you wish to cover:
Note: If you need to make any plan changes or add a member to your existing policy, please contact your agent, or you can call the number shown above for assistance.

Please enter a Florida zip code or visit the Blue Cross and Blue Shield Association to learn more about coverage available in your area.

Relationship	Gender	Date of Birth	ZIP Code	Used Tobacco in past
Relationship	Gender	Date of Birth Format: 05/18/2013	ZIP Code	Used Tobacco in past?
Relationship	Gender	Date of Birth Format: 05/18/2013	ZIP Code	Used Tobacco in past?
Relationship	Gender	Date of Birth Format: 05/18/2013	ZIP Code	Used Tobacco in past?
Relationship	Gender	Date of Birth Format: 05/18/2013	ZIP Code	Used Tobacco in past?
Relationship	Gender	Date of Birth Format: 05/18/2013	ZIP Code	Used Tobacco in past?
Relationship	Gender	Date of Birth Format: 05/18/2013	ZIP Code	Used Tobacco in past?
Relationship	Gender	Date of Birth Format: 05/18/2013	ZIP Code	Used Tobacco in past?
Relationship	Gender	Date of Birth Format: 05/18/2013	ZIP Code	Used Tobacco in past?

CWS SHP 002 072012

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