Individual Short Term Comprehensive Major Medical
Preferred Provider Organization Enrollment Application
Issued By: Capital BlueCross and Capital Advantage Insurance Company ® (Capital)
Dear Applicant,
Thank you for your interest in our Short Term coverage. We appreciate the opportunity to become your health insurer of choice.
Short Term is available for persons between the ages of 19 and 64, who are not eligible for Medicare. Dependents nineteen (19) and over must apply for their own
policy.
Be sure to read all instructions and the enclosed materials carefully before you start.
If you become covered by another plan while the policy is in force, premiums paid for this policy are nonrefundable. Remember, the Short Term policy is temporary,
nonrenewable coverage. It is not a permanent policy. If you still need temporary coverage after your policy term under this plan ends, you may apply for another new
term of Short Term coverage. The new policy term will be subject to a new deductible. And, the new policy will not cover any preexisting condition, illness, or injury,
including those that developed during your original policy term.
IMPORTANT INSTRUCTIONS
REMEMBER TO SIGN, DATE, AND RETURN THE APPLICATION. Incomplete
applications will be returned to you. The effective date of your coverage will be
determined once we receive a completed application and receipt of full
payment. Please allow approximately one week for your application to be
processed.
SEND YOUR PAYMENT WITH THIS APPLICATION. Payment for the entire length
of the policy is due at time of application. Please use the Premium Calculation
Worksheet to calculate the amount due. Your identification cards will be mailed
separately.
Capital strictly maintains the privacy of its applicants and Members. Any personal information you provide to us will be carefully protected according to federal and
state law.
If you have any questions about this application or the benefit programs offered by Capital, contact a Sales Representative at
1-800-451-1181
www.capbluecross.com
Health care benefit programs issued or administered by Capital BlueCross and its subsidiary, Capital Advantage Insurance Company®. Independent licensees of the Blue Cross and
Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.
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NF-882 (11/2012)
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NF-882 (11/2012)
Individual Short Term Comprehensive
Major Medical Preferred Provider
Organization Enrollment Application
• Full Payment Must Accompany
This Application •
Make Check Payable To And Mail To:
Capital Blue Cross
PO Box 772612, Harrisburg, PA 17177-2612
Applicant’s Name — (print last, first, middle)
Gender
Birthdate (mm/dd/yyyy)
Applicant’s Social Security Number
 Male  Female
Address (street, city, state, ZIP code)
County
Telephone Number
Email Address
Spouse’s Name (if to be insured) — (print last, first, middle)
Gender
Birthdate (mm/dd/yyyy)
Spouse’s Social Security Number
Gender
Birthdate (mm/dd/yyyy)
 Male  Female
Children (if to be insured) — (print last, first, middle) — Dependents must be less than
19 years of age
 Male  Female
 Male  Female
 Male  Female
 Male  Female
Choose Policy Term
(months)
Choose Deductible
Options
 1*
4
 $500
 $2,500
2
5
 $1,000
 $5,000
3
6
Premium (please refer to calculation worksheet on page 5,
to calculate your premium)
Requested Effective Date
(1st or 15th of the month)
Total Premium: $
Application Fee: $
10.00
Total Remittance: $
*If you select our one month policy term, please note you are entitled to benefits in accordance with 31 PA Code § 88.166(1).
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NF-882 (11/2012)
Health Status:
1.
Do you, or any person for whom application is made, now have any other health insurance, Medicare, or Medicaid?
If YES, this policy cannot be issued.
 Yes
 No
2.
Is any individual applying for coverage currently pregnant, expecting a child with anyone, an expectant or surrogate parent, or in the process of
adopting a child? If YES, this policy cannot be issued.
 Yes
 No
3.
Have you, or any person for whom application is made, been declined for insurance due to health reasons within the last five (5) years?
If YES, this policy cannot be issued.
 Yes
 No
A. Has Capital BlueCross previously issued two, consecutive, Short Term medical policies to you, or any person for whom the application
is made?
 Yes
 No
B. If you answered YES to question 4A, did your policy terminate in the last six months? If YES, this policy cannot be issued.
 Yes
 No
Are you, or any person for whom application is made, a non‑United States citizen? If YES, this policy cannot be issued.
 Yes
 No
 Yes
 No
4.
5.
Have you, or any person for whom application is made, within the last five (5) years, been notified by your physician of any abnormal test
results; received medical or surgical treatment; consulted with a licensed medical professional; or taken medication for any of the following
conditions? If YES, this policy cannot be issued.
6.
a.Heart disorder including but not limited to heart attack or chest pain
b.Alcoholism, chemical dependency, or drug and/or alcohol abuse
c.Crohn’s disease, ulcerative colitis or hepatitis, GERD or gastritis
d.AIDS or tested positive for HIV
e.Emphysema
f.Diabetes
g.Stroke
h.Mental health issues
i.Kidney disorders, excluding kidney stones
j.Migraines
k.Cancer or tumor
l.Neurological disorders
m.Obesity
IMPORTANT NOTE: If you selected “Yes” to any of the above questions, then you are not eligible for our Short Term plan and you should not send your
application or payment to us.
I UNDERSTAND THAT:
(1) PREEXISTING CONDITIONS ARE NOT COVERED BY THIS POLICY; and
(2) The coverage under this policy is not renewable; and
(3) The policy will not be issued to persons attaining the age of 65 during the benefit period; and
(4) Addition of dependents is not permitted after the policy has been issued.
I REPRESENT THAT ALL INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT AND ACKNOWLEDGE THAT MY COVERAGE IS SUBJECT TO CANCELLATION
IF ANY INFORMATION IS FOUND TO BE FALSE OR INCORRECT.
Applicant’s Name
Applicant’s Signature
Date
I verify that the information given in this enrollment application is true and correct. Any person who knowingly and with intent to defraud any
insurance company or other person, files an application for insurance or statement of claim containing any materially false information or conceals for the
purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to
criminal and civil penalties.
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NF-882 (11/2012)
Please select your payment option:  Personal Check  Money Order  Bill Payer  Credit Card Please complete the following information if using Bill Payer.
If paying with Credit Card, please go to www.capbluecross.com/products/forindividuals/individualshortterm/.
Name on Account
Name of Insured
Financial Institution’s Name
Date Payment Will Be Transferred
Financial Institution’s Confirmation Number
If you have questions regarding our product, please contact our Sales team at: 1-800-451-1181
Remit Application and Payment to:
Capital BlueCross
PO Box 772612
Harrisburg, PA 17177-2612
Or, if you are submitting your payment via Bill Payer, you may fax your application to: 717-541-6667
Premium Calculation Worksheet
Step 1. List the monthly rate applicable for you/your family, based off of the age and gender of the oldest applicant and the
deductible level you are applying for on line A.
A.$
Step 2. Enter the number of months you are seeking coverage for (maximum number of months is six 6).
B.$
Step 3. Multiply line A by line B and enter total on line C.
C.$
Step 4. Add Application Fee (nonrefundable).
D.$
Step 5. Add lines C and D. This is the total amount to be submitted with your completed application.
10.00
Total $
Carefully check the premium calculation worksheet. Incorrect premium calculations will result in your application being returned and delay processing.
Producer (please print) — (to be completed by producers only)
Signature of Producer
Name (Producer)
Producer ID #
Name (General Agent)
Producer’s Email
IA/ST/APP v2
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Signature of Producer
Date
NF-882 (11/2012)
Rates
$500 Deductible
Male
Age Bracket
19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
Single
$61.00
$61.00
$61.00
$76.00
$89.00
$107.00
$130.00
$156.00
$196.00
$249.00
$500 Deductible
Parent
and Child
$95.00
$95.00
$95.00
$110.00
$124.00
$141.00
$163.00
$191.00
$230.00
$283.00
Parent
and Children
$130.00
$130.00
$130.00
$144.00
$158.00
$174.00
$197.00
$224.00
$263.00
$317.00
Husband
and Wife
$139.00
$139.00
$139.00
$169.00
$195.00
$227.00
$266.00
$314.00
$378.00
$470.00
Parent
and Child
$83.00
$83.00
$83.00
$96.00
$107.00
$122.00
$141.00
$165.00
$198.00
$243.00
Parent
and Children
$112.00
$112.00
$112.00
$125.00
$136.00
$151.00
$170.00
$193.00
$227.00
$273.00
Husband
and Wife
$121.00
$121.00
$121.00
$147.00
$169.00
$196.00
$230.00
$271.00
$325.00
$403.00
Parent
and Child
$67.00
$67.00
$67.00
$76.00
$85.00
$97.00
$111.00
$130.00
$156.00
$191.00
Parent
and Children
$89.00
$89.00
$89.00
$100.00
$109.00
$120.00
$135.00
$153.00
$179.00
$215.00
Husband
and Wife
$97.00
$97.00
$97.00
$117.00
$134.00
$154.00
$181.00
$212.00
$256.00
$316.00
Parent
and Child
$53.00
$53.00
$53.00
$61.00
$67.00
$76.00
$87.00
$100.00
$120.00
$147.00
Parent
and Children
$71.00
$71.00
$71.00
$78.00
$85.00
$94.00
$105.00
$119.00
$139.00
$165.00
Husband
and Wife
$76.00
$76.00
$76.00
$91.00
$104.00
$120.00
$140.00
$164.00
$196.00
$242.00
Female
Family
$206.00
$206.00
$206.00
$236.00
$263.00
$295.00
$334.00
$381.00
$446.00
$537.00
Age Bracket
19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
$1,000 Deductible
Male
Age Bracket
19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
Single
$54.00
$54.00
$54.00
$67.00
$78.00
$93.00
$112.00
$135.00
$169.00
$215.00
Age Bracket
19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
Single
$43.00
$43.00
$43.00
$54.00
$63.00
$74.00
$89.00
$106.00
$132.00
$169.00
Female
Family
$180.00
$180.00
$180.00
$205.00
$228.00
$254.00
$288.00
$329.00
$384.00
$462.00
Age Bracket
19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
Age Bracket
19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
Single
$35.00
$35.00
$35.00
$42.00
$49.00
$57.00
$69.00
$82.00
$102.00
$128.00
Parent
and Children
$148.00
$148.00
$148.00
$163.00
$176.00
$190.00
$206.00
$227.00
$252.00
$290.00
Husband
and Wife
$139.00
$139.00
$139.00
$169.00
$195.00
$227.00
$266.00
$314.00
$378.00
$470.00
Family
$206.00
$206.00
$206.00
$236.00
$263.00
$295.00
$334.00
$381.00
$446.00
$537.00
Single
$70.00
$70.00
$70.00
$82.00
$94.00
$106.00
$121.00
$138.00
$159.00
$191.00
Parent
and Child
$99.00
$99.00
$99.00
$111.00
$123.00
$135.00
$150.00
$167.00
$189.00
$221.00
Parent
and Children
$128.00
$128.00
$128.00
$141.00
$152.00
$165.00
$179.00
$196.00
$217.00
$250.00
Husband
and Wife
$121.00
$121.00
$121.00
$147.00
$169.00
$196.00
$230.00
$271.00
$325.00
$403.00
Family
$180.00
$180.00
$180.00
$205.00
$228.00
$254.00
$288.00
$329.00
$384.00
$462.00
Parent
and Child
$79.00
$79.00
$79.00
$89.00
$98.00
$107.00
$119.00
$132.00
$148.00
$174.00
Parent
and Children
$102.00
$102.00
$102.00
$112.00
$121.00
$130.00
$141.00
$154.00
$171.00
$197.00
Husband
and Wife
$97.00
$97.00
$97.00
$117.00
$134.00
$154.00
$181.00
$212.00
$256.00
$316.00
Family
$143.00
$143.00
$143.00
$163.00
$180.00
$201.00
$228.00
$259.00
$302.00
$362.00
Parent
and Child
$63.00
$63.00
$63.00
$70.00
$76.00
$83.00
$92.00
$102.00
$115.00
$134.00
Parent
and Children
$80.00
$80.00
$80.00
$87.00
$95.00
$102.00
$110.00
$120.00
$133.00
$152.00
Husband
and Wife
$76.00
$76.00
$76.00
$91.00
$104.00
$120.00
$140.00
$164.00
$196.00
$242.00
Family
$113.00
$113.00
$113.00
$128.00
$141.00
$156.00
$176.00
$200.00
$232.00
$278.00
$2,500 Deductible
Female
Family
$143.00
$143.00
$143.00
$163.00
$180.00
$201.00
$228.00
$259.00
$302.00
$362.00
Age Bracket
19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
$5,000 Deductible
Male
Parent
and Child
$114.00
$114.00
$114.00
$128.00
$143.00
$156.00
$173.00
$193.00
$219.00
$256.00
$1,000 Deductible
$2,500 Deductible
Male
Single
$80.00
$80.00
$80.00
$95.00
$108.00
$123.00
$139.00
$160.00
$185.00
$223.00
Single
$56.00
$56.00
$56.00
$65.00
$74.00
$84.00
$95.00
$108.00
$125.00
$150.00
$5,000 Deductible
Female
Family
$113.00
$113.00
$113.00
$128.00
$141.00
$156.00
$176.00
$200.00
$232.00
$278.00
Age Bracket
19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
Single
$44.00
$44.00
$44.00
$52.00
$58.00
$65.00
$74.00
$84.00
$97.00
$115.00
Use age attained on the effective date of the policy.
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NF-882 (11/2012)