Vermont Freedom Plan Direct Pay Application

Page 1

Subscriber Information
* First Name:
 
* Last Name:
 
* Social Security Number:
 
* Date of Birth:
 
* Gender:

Note: Address given here must be a "Physical Address" (911 address) and not a Post Office Box.
* Physical Address:
 
* City:
 
* State:
 
* Zip Code:
 
This is also my Mailing Address:
   
Please enter your mailing address here.
Mailing Address:
 
City:
 
State:
 
Zip:
 

Email:
 
* Home Phone:
 
Daytime Phone:
 

* Membership Type:
* Marital Status:
* Action:
* Requested Effective Date:
 
* Coverage Option:
* Please select your employment status:
*
Is there a group insurance plan offered at your place of employment? If not employed, select "No."
   
*
Do you have existing health care coverage that you would be replacing with this coverage?
   
Are you currently a BlueCross BlueShield of Vermont customer?