Enrollment Kits and Forms

Please be sure to make three (3) copies of each application form. One should be retained by the member and the other two are for the HBR.

Enrollment kit for new employees of BEACON agencies/entities (1.71 MB)
This kit contains all the enrollment materials for new employees of agencies and entities using the BEACON system.

Enrollment kit for new employees of public schools, community colleges
and universities (1.83 MB)
This kit contains all the enrollment materials for new employees of public schools, community colleges and universities.

Change Form

Control Sheet
Form used when sending enrollment applications to BCBS.

Warehouse Requisition
Use this form to order enrollment kits and important forms.