Application for Individual Coverage
Who is this for?
If you're shopping for health insurance and you're ready to apply for one of our individual PPO plans, use this application.
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.
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:
|Blue Cross Blue Shield of Michigan
600 E. Lafayette Blvd.
Mail Code 609B
Detroit, MI 48226-2998
- Individual and family health insurance - check out our MyBlue℠ plan options designed to fit your health care needs and your budget.
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- How can I know I'm purchasing the right health insurance policy