Use this form to add new dependents to an existing policy, cancel coverage, change plan benefits elections, or transfer subscribers from one group to another within the same account. Please see the back page for further instructions. Be sure to save a copy of your completed form for your records.

If you have any questions, contact your broker or BCBSRI account representative.

Requestor Information
Member and Request Details
BCBSRI Member ID Number Name Suffix Date of Birth Operations
Common law marriage template is here.
Declaration of domestic partnership template is here.
Large group member application template is here.
Small group member application template is here.
For dependent /birthday of depdendent over age 26, please upload medical certification. Template is here.
Additional Information
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