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Are you eligible for Medicare Disability? *
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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).
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A dependent can be a spouse, domestic partner (if applicable), and/or eligible child, (by birth, adoption or legal guardianship).
you wish to cover:

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

Note: Temporary Coverage is not available for dependents less than 42 days old.

Relationship	Gender	Date of Birth (mm/dd/yyyy)	ZIP Code	County	Used Tobacco in last 12 months
Relationship	Gender	Date of Birth Format: 05/16/2012	ZIP Code		Used Tobacco in past 12 months Yes No
Relationship	Gender	Date of Birth Format: 05/16/2012	ZIP Code		Used Tobacco in past 12 months Yes No
Relationship	Gender	Date of Birth Format: 05/16/2012	ZIP Code		Used Tobacco in past 12 months Yes No
Relationship	Gender	Date of Birth Format: 05/16/2012	ZIP Code		Used Tobacco in past 12 months Yes No
Relationship	Gender	Date of Birth Format: 05/16/2012	ZIP Code		Used Tobacco in past 12 months Yes No
Relationship	Gender	Date of Birth Format: 05/16/2012	ZIP Code		Used Tobacco in past 12 months Yes No
Relationship	Gender	Date of Birth Format: 05/16/2012	ZIP Code		Used Tobacco in past 12 months Yes No
Relationship	Gender	Date of Birth Format: 05/16/2012	ZIP Code		Used Tobacco in past 12 months Yes No

CWS SHP 002 042012

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