Blue Cross Blue Shield of Minnesota Options Blue Application
Name:
Phone:
Address:
City:
State:
Zip:
E-mail:


Steven A. Ehlen, Agent #HFBE6161
MN Insurance license #200889301

Holland & Frank Executive and
Employee Benefit Solutions, Inc
Independent Agent for Blue Cross Blue Shield of Minnesota
1101 2nd St. S. Suite 110
Sartell, MN 56377

 Office:       (320) 252-2799
Toll-free:   (888) 577-1142
Fax:            (320) 257-4584
                   (877) 577-5437

E-mail: steve@hollandandfrank.com
Has anyone applying for coverage been declined by another health insurance company within the past year?
Yes
No

Has anyone applying for coverage been convicted of a DWI/DUI within the past year or been treated for drug or alcohol use within the past 5 years?
Yes
No

Will any person applying for coverage reside outside of Minnesota during the next year?
Yes
No

Has anyone applying for coverage been diagnosed or treated within the past 5 years for a MAJOR DISORDER of the heart, lungs, kidneys, or liver, or been treated for a stroke, cancer, or diabetes, or is anyone currently pregnant or expecting to add a dependent through adoption?
Yes
No

If you answered yes to any of the above questions your application might be declined by the health insurance underwriter. If you would like to discuss your medical history or are interested in cost effective guaranteed issue coverage, contact Steven A Ehlen directly at 888-577-1142.
Yes
No
Click continue for the rest of the application.
Print and fill out application then send to Blue Cross Blue Shield of Minnesota return address in upper left corner of application along with selected premium payment option .