Transcription of APPLICATION FOR A CHANGE IN COVERAGE
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APPLICATION FOR A CHANGE IN COVERAGE
APPLICATION FOR. Box 3236, Naperville, IL 60566-7236. A CHANGE IN COVERAGE . Print all answers in blue or black ink. Pencil will not be accepted. Please check only one box below to tell us why you are requesting a CHANGE in COVERAGE . To become the Primary Policyholder of my health COVERAGE because I am at least age 26, or at least age 30 if a military veteran, currently covered under a parent's or guardian's policy, and not eligible for permanent dependent status. To become the Primary Policyholder of my health COVERAGE . (If this request is due to the death of your spouse, please include a copy of the death certificate.). To choose a new Blue Cross and Blue Shield of Illinois health insurance plan with less comprehensive benefits.
of Illinois health insurance policy. ... APPLICATION FOR A CHANGE IN COVERAGE P.O. Box 3236, Naperville, IL 60566-7236 ... or intentional misrepresentations of a material fact that are made on this application or any act or practice that constitutes fraud, will result in the cancellation of my or my spouse and/or dependent child(ren)'s coverage ...
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