Application for Individual Coverage

If you're ready to get started with one of our individual PPO plans, you can fill out this application.

If you have any questions, call the Customer Service number on the back of your enrollee ID card.

Blue Cross Blue Shield of Michigan Application for Individual Coverage (PDF)

What you'll need:

• The personal information of anyone who'll be covered by the plan, including social security number, date of birth, height, weight and driver's license number/state ID number (if age 19 or over)
  
• Your bank account number, your bank's routing number, a deposit slip and a blank, voided check if you want to set up automatic premium payments
• A printer to print the form 
• An envelope and postage to mail the form

Fill out the form completely and send it to:

Related Items

• Individual and family health insurance - check out our MyBlue℠ plan options designed to fit your health care needs and your budget.
• How to purchase individual health insurance
• How can I know I'm purchasing the right health insurance policy