Census Form For Quoting Purposes
Instructions for completing columns 4-7
- # of Total Members: Enter total number of members that will have regular BCBSM/BCN coverage.
- # of Medicare Eligible: Enter total number of members that are medicare eligible but have BSBSM or BCN as their primary coverage.
- # of Medicare Primary: Enter total number of members that are Medicare eligible and have Medicare as their primary coverage.
This is not an offer to sell insurance. Insurance coverage cannot be bound or changed via submission of this online form. Note that any proposal of insurance we may present to you will be based upon the values developed and exposures to loss disclosed to us on this online form and/or in communications with us. All coverage is subject to the terms, conditions and exclusions of the actual policy issued.