secure.bcbssettlement.com
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2620:1ec:bdf::44
Public Scan
Submitted URL: https://email.bcbssettlement.com/c/eJxljz1vgzAYhH8NjMivjfkYPAAGgZoQibB0ssC8aaxiiMD8_5KqW6Wb7h6d7iYRJjTi3DeCEgpAgBISUhoHEHBguczTTK...
Effective URL: https://secure.bcbssettlement.com/?utm_medium=Link2_en&utm_source=DirectNotice_Email&utm_campaign=BCBS21
Submission: On October 12 via api from US — Scanned from DE
Effective URL: https://secure.bcbssettlement.com/?utm_medium=Link2_en&utm_source=DirectNotice_Email&utm_campaign=BCBS21
Submission: On October 12 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST /en/form/insertclaim
<form autocomplete="off" method="post" id="fullClaimForm" action="/en/form/insertclaim" novalidate="novalidate">
<input type="hidden" autocomplete="off" name="g-recaptcha-response" id="GoogleReCaptchaResponse" value="">
<input name="culture" autocomplete="off" type="hidden" value="en">
<div class="row">
<div class="col-md-12">
<!-- SECTION 0. -->
<section id="section0" class="show-on-load narrow-panel">
<div class="login-wrapper">
<div class="row">
<div class="col-sm-12">
<div class="title-icon">
<h2>
<i class="fal fa-file-invoice-dollar"></i> Online Claim Form
</h2>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="title-desc">
<p> Please enter the Unique ID contained in the <a data-html="true" data-toggle="popover" title="" data-content="<img src='https://www.bcbssettlement.com/shk/ocf/images/Email_ID.png' alt='JND Legal Administration'>" data-trigger="manual" tabindex="0" data-original-title="Email">
email
<i class="fa fa-info-circle"></i>
</a> or on the <a data-html="true" data-offset="-25" data-toggle="popover" title="" data-content="<img src='https://www.bcbssettlement.com/shk/ocf/images/Postcard_ID.png' alt='JND Legal Administration'>" data-trigger="manual" tabindex="0" data-original-title="Postcard">
postcard
<i class="fa fa-info-circle"></i>
</a> notice that you received and click Login. </p>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<label class="control-label" for="UniqueId">Unique ID</label>
<input autocomplete="off" type="text" class="form-control" maxlength="100" data-val="true" data-val-regex="Invalid ID"
data-val-regex-pattern="^[a-hA-Hj-nJ-Np-zP-Z2-9]{3}[bB][a-hA-Hj-nJ-Np-zP-Z2-9](-){0,1}[a-hA-Hj-nJ-Np-zP-Z2-9]{2}[cCsS][a-hA-Hj-nJ-Np-zP-Z2-9]{2}$" id="UniqueId" name="UniqueId" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="UniqueId" data-valmsg-replace="true"></span>
<button type="button" id="submitClaimNumberBtn" class="btn btn-primary btn-block mt-2"> LOGIN <i class="fa fa-arrow-right"></i>
</button>
</div>
</div>
</div>
<div class="no-login-wrapper">
<div class="row">
<div class="col-sm-12">
<div class="text-center">
<h5 class="mb-2"> Don't have a Unique ID? </h5>
<a id="submitClaimNumberLink">
File a claim here <i class="fa fa-arrow-right"></i>
</a>
</div>
</div>
</div>
</div>
</section>
<!-- SECTION 1. -->
<section id="section1">
<div id="business-or-individual-options">
<div class="row mb-5">
<div class="col-sm-12">
<h3> Are you filing for a <a data-html="true" data-toggle="popover" data-content="To be completed only on behalf of companies/businesses/entities that purchased BCBS health insurance or administrative services plans from a BCBS company." data-trigger="manual" tabindex="0" data-original-title="" title="">
business
<i class="fa fa-info-circle"></i>
</a> or are you filing for <a data-html="true" data-toggle="popover" data-content="To be completed only by (1) individuals who were enrolled in BCBS health insurance or administrative services plans through their employers or who otherwise purchased BCBS health insurance or administrative services plans through other group entities, or (2) individuals who purchased health insurance directly from a BCBS company." data-trigger="manual" tabindex="0" data-original-title="" title="">
yourself
<i class="fa fa-info-circle"></i>
</a> ? </h3>
</div>
</div>
<div class="row mb-4">
<div class="col-md-6">
<div class="filing-option option" data-option="1" tabindex="0" role="button" style="height: 152px;">
<div class="wrapper">
<div class="text">
<h3>Business</h3>
</div>
<div class="icon"><i class="fal fa-building"></i></div>
</div>
</div>
</div>
<div class="col-md-6">
<div id="myself-option" class="filing-option option" tabindex="0" role="button" style="height: 152px;">
<div class="wrapper">
<div class="text">
<h3>Myself</h3>
</div>
<div class="icon"><i class="fal fa-user"></i></div>
</div>
</div>
</div>
</div>
</div>
<div id="individual-options" style="display:none;">
<div class="row mb-5">
<div class="col-sm-12">
<h3> Were you enrolled through your <a data-html="true" data-toggle="popover" data-content="To be completed only by individuals who were enrolled in BCBS health insurance or administrative services plans through their employers or who otherwise purchased BCBS health insurance or administrative services plans through other group entities." data-trigger="manual" tabindex="0" data-original-title="" title="">
employer or other entity
<i class="fa fa-info-circle"></i>
</a> , or did you buy insurance <a data-html="true" data-toggle="popover" data-content="To be completed only by individuals who purchased health insurance for their own or their family’s use directly from a BCBS company." data-trigger="manual" tabindex="0" data-original-title="" title="">
directly
<i class="fa fa-info-circle"></i>
</a> from a BCBS company, or do both? </h3>
</div>
</div>
<div class="row">
<div class="col-lg-4">
<div class="option individual-option" data-option="2" tabindex="0" role="button" style="height: 152px;">
<div class="wrapper">
<div class="text">
<h3>Enrolled through Employer</h3>
</div>
<div class="icon"><i class="fal fa-user"></i></div>
</div>
</div>
</div>
<div class="col-lg-4">
<div class="option individual-option" data-option="3" tabindex="0" role="button" style="height: 152px;">
<div class="wrapper">
<div class="text">
<h3>Purchased Myself</h3>
</div>
<div class="icon"><i class="fal fa-user"></i></div>
</div>
</div>
</div>
<div class="col-lg-4">
<div class="option individual-option" data-option="4" tabindex="0" role="button" style="height: 152px;">
<div class="wrapper">
<div class="text">
<h3>Both</h3>
</div>
<div class="icon"><i class="fal fa-user-plus"></i></div>
</div>
</div>
</div>
</div>
</div>
<input autocomplete="off" type="hidden" id="SelectedFilingOption" name="SelectedFilingOption" value="">
<div class="clear-data-warning modal fade" tabindex="-1" role="dialog">
<div class="modal-dialog modal-lg" role="document">
<div class="modal-content">
<input type="hidden" autocomplete="off" id="target-filing-option" name="target-filing-option">
<div class="modal-header">
<button type="button" class="close float-right" data-dismiss="modal" aria-label="Close">
<span aria-hidden="true">×</span>
</button>
</div>
<div class="modal-body">
<i class="fal fa-info-circle"></i>
<p>You have selected a new filing option. Any data you entered for the previous selection will not be saved. Do you want to continue?</p>
</div>
<div class="modal-footer">
<button type="button" class="btn btn-primary-outline mr-auto" data-dismiss="modal">
<i class="fa fa-times"></i> Cancel </button>
<button type="button" class="btn btn-primary clear-data-option float-right" data-dismiss="modal">
<i class="fa fa-check"></i> Yes </button>
</div>
</div>
</div>
</div>
</section>
</div>
</div>
<div class="row">
<div class="col-md-2 col-lg-3 flow-steps-column">
<!-- FLOW STEPS -->
<div id="flowSteps" style="display: none">
<!-- #region OPTION 1. -->
<div class="flowOption1 flowOption" style="display: none">
<div class="flowStep flowStep10 jump-backward-navigation currentFlowStep" data-navstep="11" data-navoption="1" style="overflow: hidden">
<div class="flowGroup">
<div class="flowCheck"><i class="fa fa-check"></i></div>
<div class="flowNum">1</div>
<div class="flowLine"></div>
</div>
<div class="flowTitle">Business Information</div>
</div>
<div class="flowStep flowStep11 jump-backward-navigation" data-navstep="12" data-navoption="1" style="overflow: hidden">
<div class="flowGroup">
<div class="flowCheck"><i class="fa fa-check"></i></div>
<div class="flowNum">2</div>
<div class="flowLine"></div>
</div>
<div class="flowTitle">Health Plan Details</div>
</div>
<div class="flowStep flowStep12 jump-backward-navigation" data-navstep="13" data-navoption="1" style="overflow: hidden">
<div class="flowGroup">
<div class="flowCheck"><i class="fa fa-check"></i></div>
<div class="flowNum">3</div>
<div class="flowLine"></div>
</div>
<div class="flowTitle">Allocation of Premiums</div>
</div>
<div class="flowStep flowStep13 jump-backward-navigation" data-navstep="14" data-navoption="1" style="overflow: hidden">
<div class="flowGroup">
<div class="flowCheck"><i class="fa fa-check"></i></div>
<div class="flowNum">4</div>
<div class="flowLine"></div>
</div>
<div class="flowTitle">Payment Election</div>
</div>
<div class="flowStep flowStep14 jump-backward-navigation" data-navstep="15" data-navoption="1" style="overflow: hidden">
<div class="flowGroup">
<div class="flowCheck"><i class="fa fa-check"></i></div>
<div class="flowNum">5</div>
</div>
<div class="flowTitle">Review & Signature</div>
</div>
</div>
<!-- #endregion -->
<!-- #region OPTION 2. -->
<div class="flowOption2 flowOption" style="display: none">
<div class="flowStep flowStep20 jump-backward-navigation" data-navstep="21" data-navoption="2" currentflowstep"="" style="overflow: hidden">
<div class="flowGroup">
<div class="flowCheck"><i class="fa fa-check"></i></div>
<div class="flowNum">1</div>
<div class="flowLine"></div>
</div>
<div class="flowTitle">Subscriber Information</div>
</div>
<div class="flowStep flowStep21 jump-backward-navigation" data-navstep="22" data-navoption="2" style="overflow: hidden">
<div class="flowGroup">
<div class="flowCheck"><i class="fa fa-check"></i></div>
<div class="flowNum">2</div>
<div class="flowLine"></div>
</div>
<div class="flowTitle">Health Plan Details</div>
</div>
<div class="flowStep flowStep22 jump-backward-navigation" data-navstep="23" data-navoption="2" style="overflow: hidden">
<div class="flowGroup">
<div class="flowCheck"><i class="fa fa-check"></i></div>
<div class="flowNum">3</div>
<div class="flowLine"></div>
</div>
<div class="flowTitle">Allocation of Premiums</div>
</div>
<div class="flowStep flowStep23 jump-backward-navigation" data-navstep="24" data-navoption="2" style="overflow: hidden">
<div class="flowGroup">
<div class="flowCheck"><i class="fa fa-check"></i></div>
<div class="flowNum">4</div>
<div class="flowLine"></div>
</div>
<div class="flowTitle">Payment Election</div>
</div>
<div class="flowStep flowStep24 jump-backward-navigation" data-navstep="25" data-navoption="2" style="overflow: hidden">
<div class="flowGroup">
<div class="flowCheck"><i class="fa fa-check"></i></div>
<div class="flowNum">5</div>
</div>
<div class="flowTitle">Review & Signature</div>
</div>
</div>
<!-- #endregion -->
<!-- #region OPTION 3. -->
<div class="flowOption3 flowOption" data-navstep="31" data-navoption="3" style="display: none">
<div class="flowStep flowStep30 jump-backward-navigation currentFlowStep" data-navstep="31" data-navoption="3" style="overflow: hidden">
<div class="flowGroup">
<div class="flowCheck"><i class="fa fa-check"></i></div>
<div class="flowNum">1</div>
<div class="flowLine"></div>
</div>
<div class="flowTitle">Subscriber Information</div>
</div>
<div class="flowStep flowStep31 jump-backward-navigation" data-navstep="32" data-navoption="3" style="overflow: hidden">
<div class="flowGroup">
<div class="flowCheck"><i class="fa fa-check"></i></div>
<div class="flowNum">2</div>
<div class="flowLine"></div>
</div>
<div class="flowTitle">Health Plan Details</div>
</div>
<div class="flowStep flowStep32 jump-backward-navigation" data-navstep="33" data-navoption="3" style="overflow: hidden">
<div class="flowGroup">
<div class="flowCheck"><i class="fa fa-check"></i></div>
<div class="flowNum">3</div>
<div class="flowLine"></div>
</div>
<div class="flowTitle">Payment Election</div>
</div>
<div class="flowStep flowStep33 jump-backward-navigation" data-navstep="34" data-navoption="3" style="overflow: hidden">
<div class="flowGroup">
<div class="flowCheck"><i class="fa fa-check"></i></div>
<div class="flowNum">4</div>
</div>
<div class="flowTitle">Review & Signature</div>
</div>
</div>
<!-- #endregion -->
<!-- #region OPTION 4. -->
<div class="flowOption4 flowOption" style="display: none">
<div class="flowStep flowStep40 jump-backward-navigation currentFlowStep" data-navstep="41" data-navoption="4" style="overflow: hidden">
<div class="flowGroup">
<div class="flowCheck"><i class="fa fa-check"></i></div>
<div class="flowNum">1</div>
<div class="flowLine"></div>
</div>
<div class="flowTitle">Subscriber Information</div>
</div>
<div class="flowStep flowStep41 jump-backward-navigation" data-navstep="42" data-navoption="4" style="overflow: hidden">
<div class="flowGroup">
<div class="flowCheck"><i class="fa fa-check"></i></div>
<div class="flowNum">2</div>
<div class="flowLine"></div>
</div>
<div class="flowTitle">Health Plan Details</div>
</div>
<div class="flowStep flowStep42 jump-backward-navigation" data-navstep="43" data-navoption="4" style="overflow: hidden">
<div class="flowGroup">
<div class="flowCheck"><i class="fa fa-check"></i></div>
<div class="flowNum">3</div>
<div class="flowLine"></div>
</div>
<div class="flowTitle">Allocation of Premiums</div>
</div>
<div class="flowStep flowStep43 jump-backward-navigation" data-navstep="44" data-navoption="4" style="overflow: hidden">
<div class="flowGroup">
<div class="flowCheck"><i class="fa fa-check"></i></div>
<div class="flowNum">4</div>
<div class="flowLine"></div>
</div>
<div class="flowTitle">Payment Election</div>
</div>
<div class="flowStep flowStep44 jump-backward-navigation" data-navstep="45" data-navoption="4" style="overflow: hidden">
<div class="flowGroup">
<div class="flowCheck"><i class="fa fa-check"></i></div>
<div class="flowNum">5</div>
</div>
<div class="flowTitle">Review & Signature</div>
</div>
</div>
<!-- #endregion -->
</div>
</div>
<div class="col-md-10 col-lg-9">
<!-- #region OPTION 1. -->
<div id="business-flow">
<!-- SECTION 11. -->
<section id="option1section11" class="datalosswarning-on">
<div class="question-group">
<div class="form-horizontal">
<div class="row title-icon">
<div class="col-md-12">
<h2>
<i class="fal fa-building"></i> Business Information
</h2>
</div>
</div>
<div class="row title-desc">
<div class="col-md-12"> Please provide the following information: </div>
</div>
<div class="row sub-title">
<div class="col-md-12">
<div class="row">
<div class="col-md-12">
<div class="sub-num">1</div>
<h5>Full Name of Company</h5>
</div>
</div>
<hr>
</div>
</div>
<div class="row">
<div class="col-md-6">
<label class="control-label required-field-label" for="Business_BusinessContactInfo_CompanyName">Company</label>
<input autocomplete="off" type="text" class="form-control" maxlength="100" data-val="true" data-val-required="This is required." id="Business_BusinessContactInfo_CompanyName" name="Business.BusinessContactInfo.CompanyName" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Business.BusinessContactInfo.CompanyName" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row sub-title mt-4">
<div class="col-md-12">
<div class="row">
<div class="col-md-12">
<div class="sub-num">2</div>
<h5>Primary Headquarters Mailing Address</h5>
</div>
</div>
<hr>
</div>
</div>
<div class="row">
<div class="col-md-6">
<label class="control-label required-field-label" for="Business_Shared_MailingStreetLine1">Street Line 1</label>
<input autocomplete="off" type="text" class="form-control" maxlength="200" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" data-val-required="This is required."
id="Business_Shared_MailingStreetLine1" name="Business.Shared.MailingStreetLine1" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Business.Shared.MailingStreetLine1" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6">
<label class="control-label" for="Business_Shared_MailingStreetLine2">Street Line 2</label>
<input autocomplete="off" type="text" class="form-control" maxlength="200" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" id="Business_Shared_MailingStreetLine2"
name="Business.Shared.MailingStreetLine2" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Business.Shared.MailingStreetLine2" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-md-6 col-lg-6">
<label class="control-label required-field-label" for="Business_Shared_MailingCity">City</label>
<input autocomplete="off" type="text" class="form-control" maxlength="200" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" data-val-required="This is required."
id="Business_Shared_MailingCity" name="Business.Shared.MailingCity" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Business.Shared.MailingCity" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6 col-lg-6 div-country-us">
<label class="control-label required-field-label" for="Business_Shared_MailingSubDivision">State</label>
<select class="form-control" data-val="true" data-val-requiredif="State or Province is required." data-val-requiredif-comp="isequalto" data-val-requiredif-other="MailingCountry" data-val-requiredif-value="US"
id="Business_Shared_MailingSubDivision" name="Business.Shared.MailingSubDivision">
<option value="" selected="selected"></option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AS">American Samoa</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="GU">Guam</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MP">Northern Mariana Islands</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="PR">Puerto Rico</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="VI">U.S. Virgin Islands</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
<option value="AA">AA</option>
<option value="AP">AP</option>
<option value="AE ">AE </option>
</select>
<span class="text-danger field-validation-valid" data-valmsg-for="Business.Shared.MailingSubDivision" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6 col-lg-6 div-country-non-us" style="display:none">
<label class="control-label required-field-label" for="Business_Shared_MailingSubDivisionNonUS">Province</label>
<input autocomplete="off" type="text" class="form-control province" maxlength="200" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200"
data-val-requiredif="State or Province is required." data-val-requiredif-comp="isnotequalto" data-val-requiredif-other="MailingCountry" data-val-requiredif-value="US" id="Business_Shared_MailingSubDivisionNonUS"
name="Business.Shared.MailingSubDivisionNonUS" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Business.Shared.MailingSubDivisionNonUS" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-md-6 col-lg-6 div-country-us">
<label class="control-label required-field-label" for="Business_Shared_MailingPostalCode">Zip</label>
<input autocomplete="off" type="text" class="zip form-control" maxlength="10" data-val="true" data-val-maxlength="This field can contain a maximum of 10 characters." data-val-maxlength-max="10"
data-val-regex="Please enter a five- or nine-digit ZIP code." data-val-regex-pattern="^\d{5}(?:[-\s]?\d{4})?$" data-val-requiredif="ZIP Code is required." data-val-requiredif-comp="isequalto"
data-val-requiredif-other="MailingCountry" data-val-requiredif-value="US" id="Business_Shared_MailingPostalCode" name="Business.Shared.MailingPostalCode" value="">
<span class="text-danger zip field-validation-valid" data-valmsg-for="Business.Shared.MailingPostalCode" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6 col-lg-6 div-country-non-us" style="display:none">
<label class="control-label required-field-label text-truncate" for="Business_Shared_MailingPostalCodeNonUS">Postal Code</label>
<input autocomplete="off" type="text" class="form-control" maxlength="10" data-val="true" data-val-maxlength="This field can contain a maximum of 10 characters." data-val-maxlength-max="10"
data-val-requiredif="Postal Code is required." data-val-requiredif-comp="isnotequalto" data-val-requiredif-other="MailingCountry" data-val-requiredif-value="US" id="Business_Shared_MailingPostalCodeNonUS"
name="Business.Shared.MailingPostalCodeNonUS" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Business.Shared.MailingPostalCodeNonUS" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6 col-lg-6">
<label class="control-label required-field-label" for="Business_Shared_MailingCountry">Country</label>
<select class="form-control" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" data-val-required="Country is required." id="Business_Shared_MailingCountry"
name="Business.Shared.MailingCountry">
<option value="" selected="selected"></option>
<option value="AD">Andorra</option>
<option value="AF">Afghanistan</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AL">Albania</option>
<option value="AM">Armenia</option>
<option value="AO">Angola</option>
<option value="AR">Argentina</option>
<option value="AT">Austria</option>
<option value="AU">Australia</option>
<option value="AZ">Azerbaijan</option>
<option value="BA">Bosnia and Herzegovina</option>
<option value="BB">Barbados</option>
<option value="BD">Bangladesh</option>
<option value="BE">Belgium</option>
<option value="BF">Burkina Faso</option>
<option value="BG">Bulgaria</option>
<option value="BH">Bahrain</option>
<option value="BI">Burundi</option>
<option value="BJ">Benin</option>
<option value="BN">Brunei Darussalam</option>
<option value="BO">Bolivia(Plurinational State of)</option>
<option value="BR">Brazil</option>
<option value="BS">Bahamas</option>
<option value="BT">Bhutan</option>
<option value="BW">Botswana</option>
<option value="BY">Belarus</option>
<option value="BZ">Belize</option>
<option value="CA">Canada</option>
<option value="CF">Central African Republic</option>
<option value="CG">Congo</option>
<option value="CI">Côte d'Ivoire</option>
<option value="CV">Cape Verde</option>
<option value="CL">Chile</option>
<option value="CM">Cameroon</option>
<option value="CN">China</option>
<option value="CO">Colombia</option>
<option value="CR">Costa Rica</option>
<option value="CU">Cuba</option>
<option value="KM">Comoros</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="DE">Germany</option>
<option value="DJ">Djibouti</option>
<option value="CD">Democratic Republic of the Congo</option>
<option value="DK">Denmark</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="DZ">Algeria</option>
<option value="EC">Ecuador</option>
<option value="EE">Estonia</option>
<option value="EG">Egypt</option>
<option value="ER">Eritrea</option>
<option value="ES">Spain</option>
<option value="ET">Ethiopia</option>
<option value="FI">Finland</option>
<option value="FJ">Fiji</option>
<option value="FM">Micronesia(Federated States of)</option>
<option value="FR">France</option>
<option value="GA">Gabon</option>
<option value="GD">Grenada</option>
<option value="GE">Georgia</option>
<option value="GH">Ghana</option>
<option value="GM">Gambia</option>
<option value="GN">Guinea</option>
<option value="GQ">Equatorial Guinea</option>
<option value="GR">Greece</option>
<option value="GT">Guatemala</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HN">Honduras</option>
<option value="HR">Croatia</option>
<option value="HT">Haiti</option>
<option value="HU">Hungary</option>
<option value="ID">Indonesia</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IN">India</option>
<option value="IQ">Iraq</option>
<option value="IR">Iran(Islamic Republic of)</option>
<option value="IS">Iceland</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JO">Jordan</option>
<option value="JP">Japan</option>
<option value="KE">Kenya</option>
<option value="KG">Kyrgyzstan</option>
<option value="KH">Cambodia</option>
<option value="KI">Kiribati</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="KP">Democratic People's Republic of Korea</option>
<option value="KR">Republic of Korea</option>
<option value="KW">Kuwait</option>
<option value="KZ">Kazakhstan</option>
<option value="LA">Lao People's Democratic Republic</option>
<option value="LB">Lebanon</option>
<option value="LC">Saint Lucia</option>
<option value="LI">Liechtenstein</option>
<option value="LK">Sri Lanka</option>
<option value="LR">Liberia</option>
<option value="LS">Lesotho</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="LV">Latvia</option>
<option value="LY">Libyan Arab Jamahiriya</option>
<option value="MA">Morocco</option>
<option value="MC">Monaco</option>
<option value="MD">Republic of Moldova</option>
<option value="ME">Montenegro</option>
<option value="MG">Madagascar</option>
<option value="MH">Marshall Islands</option>
<option value="MK">The former Yugoslav Republic of Macedonia</option>
<option value="ML">Mali</option>
<option value="MM">Myanmar</option>
<option value="MN">Mongolia</option>
<option value="MR">Mauritania</option>
<option value="MT">Malta</option>
<option value="MU">Mauritius</option>
<option value="MV">Maldives</option>
<option value="MW">Malawi</option>
<option value="MX">Mexico</option>
<option value="MY">Malaysia</option>
<option value="MZ">Mozambique</option>
<option value="NA">Namibia</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NI">Nicaragua</option>
<option value="NL">Netherlands</option>
<option value="NO">Norway</option>
<option value="NP">Nepal</option>
<option value="NR">Nauru</option>
<option value="NZ">New Zealand</option>
<option value="OM">Oman</option>
<option value="PA">Panama</option>
<option value="PE">Peru</option>
<option value="PG">Papua New Guinea</option>
<option value="PH">Philippines</option>
<option value="PK">Pakistan</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PW">Palau</option>
<option value="PY">Paraguay</option>
<option value="QA">Qatar</option>
<option value="RO">Romania</option>
<option value="RS">Serbia</option>
<option value="RU">Russian Federation</option>
<option value="RW">Rwanda</option>
<option value="SA">Saudi Arabia</option>
<option value="SB">Solomon Islands</option>
<option value="SC">Seychelles</option>
<option value="SD">Sudan</option>
<option value="SE">Sweden</option>
<option value="SG">Singapore</option>
<option value="SI">Slovenia</option>
<option value="SK">Slovakia</option>
<option value="SL">Sierra Leone</option>
<option value="SM">San Marino</option>
<option value="SN">Senegal</option>
<option value="SO">Somalia</option>
<option value="SR">Suriname</option>
<option value="ZA">South Africa</option>
<option value="SS">South Sudan</option>
<option value="ST">Sao Tome and Principe</option>
<option value="SV">El Salvador</option>
<option value="SY">Syrian Arab Republic</option>
<option value="SZ">Eswatini</option>
<option value="CH">Switzerland</option>
<option value="TD">Chad</option>
<option value="TG">Togo</option>
<option value="TH">Thailand</option>
<option value="TJ">Tajikistan</option>
<option value="TL">Timor - Leste</option>
<option value="TM">Turkmenistan</option>
<option value="TN">Tunisia</option>
<option value="TO">Tonga</option>
<option value="TR">Turkey</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TV">Tuvalu</option>
<option value="TW">Taiwan</option>
<option value="UA">Ukraine</option>
<option value="UG">Uganda</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom of Great Britain and Northern Ireland</option>
<option value="TZ">United Republic of Tanzania</option>
<option selected="selected" value="US">United States of America</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="VE">Venezuela(Bolivarian Republic of)</option>
<option value="VN">Viet Nam</option>
<option value="VU">Vanuatu</option>
<option value="WS">Samoa</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select>
<span class="text-danger field-validation-valid" data-valmsg-for="Business.Shared.MailingCountry" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row sub-title mt-4">
<div class="col-md-12">
<div class="row">
<div class="col-md-12">
<div class="sub-num">3</div>
<h5>Current Company Contact (Name and Title)</h5>
</div>
</div>
<hr>
</div>
</div>
<div class="row">
<div class="col-md-4">
<label class="control-label required-field-label" for="Business_Shared_FirstName">First Name</label>
<input autocomplete="off" type="text" class="form-control" maxlength="100" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" data-val-required="This is required."
id="Business_Shared_FirstName" name="Business.Shared.FirstName" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Business.Shared.FirstName" data-valmsg-replace="true"></span>
</div>
<div class="col-md-2">
<label class="control-label text-truncate" for="Business_Shared_MiddleInitial">Middle Initial</label>
<input autocomplete="off" type="text" class="form-control" maxlength="1" data-val="true" data-val-maxlength="This field can only contain one character." data-val-maxlength-max="1" id="Business_Shared_MiddleInitial"
name="Business.Shared.MiddleInitial" value="">
</div>
<div class="col-md-6">
<label class="control-label required-field-label" for="Business_Shared_LastName">Last Name</label>
<input autocomplete="off" type="text" class="form-control" maxlength="100" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" data-val-required="This is required."
id="Business_Shared_LastName" name="Business.Shared.LastName" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Business.Shared.LastName" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6">
<label class="control-label required-field-label" for="Business_BusinessContactInfo_Title">Title</label>
<input autocomplete="off" type="text" class="form-control" maxlength="100" data-val="true" data-val-required="This is required." id="Business_BusinessContactInfo_Title" name="Business.BusinessContactInfo.Title" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Business.BusinessContactInfo.Title" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row sub-title mt-4">
<div class="col-md-12">
<div class="row">
<div class="col-md-12">
<div class="sub-num">4</div>
<h5>Office Phone Number</h5>
</div>
</div>
<hr>
</div>
</div>
<div class="row">
<div class="col-sm-6 div-country-us">
<label class="control-label required-field-label" for="Business_Shared_PhoneNumber">Office Phone Number</label>
<input autocomplete="off" type="text" maxlength="14" class="form-control phone" data-val="true" data-val-maxlength="Phone number is too long. " data-val-maxlength-max="15" data-val-regex="Invalid phone number format."
data-val-regex-pattern="^(?:\+?1[-. ]?)?\(?([0-9]{3})\)?[-. ]?([0-9]{3})[-. ]?([0-9]{4})[ ]?(x\d{1,5})?$" data-val-requiredif="This is required." data-val-requiredif-comp="isequalto" data-val-requiredif-other="MailingCountry"
data-val-requiredif-value="US" id="Business_Shared_PhoneNumber" name="Business.Shared.PhoneNumber" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Business.Shared.PhoneNumber" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-6 div-country-non-us" style="display:none">
<label class="control-label required-field-label" for="Business_Shared_PhoneNumberNonUS">Phone</label>
<input autocomplete="off" type="text" maxlength="14" class="form-control phone" data-val="true" data-val-maxlength="LocKey_PhoneNumberMustBeLimitedTo20Characters" data-val-maxlength-max="20" data-val-requiredif="This is required."
data-val-requiredif-comp="isnotequalto" data-val-requiredif-other="MailingCountry" data-val-requiredif-value="US" id="Business_Shared_PhoneNumberNonUS" name="Business.Shared.PhoneNumberNonUS" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Business.Shared.PhoneNumberNonUS" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row sub-title mt-4">
<div class="col-md-12">
<div class="row">
<div class="col-md-12">
<div class="sub-num">5</div>
<h5>Company Contact Email Address</h5>
</div>
</div>
<hr>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="control-label required-field-label" for="Business_Shared_EmailAddress">Email Address</label>
<input autocomplete="off" type="text" class="form-control" maxlength="100" data-val="true" data-val-maxlength="Email entered is too long." data-val-maxlength-max="200" data-val-regex="Invalid Email Format."
data-val-regex-pattern="^[\w!#$%&'*+\-/=?\^_`{|}~]+(\.[\w!#$%&'*+\-/=?\^_`{|}~]+)*@((([\-\w]+\.)+[a-zA-Z0-9\-]{2,})|(([0-9]{1,3}\.){3}[0-9]{1,3}))$" data-val-required="This is required." id="Business_Shared_EmailAddress"
name="Business.Shared.EmailAddress" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Business.Shared.EmailAddress" data-valmsg-replace="true"></span>
</div>
</div>
</div>
</div>
</section>
<!-- SECTION 12. -->
<section id="option1section12" class="datalosswarning-on health-plan-details-section">
<div class="question-group">
<div class="form-horizontal">
<div class="row title-icon">
<div class="col-sm-12">
<h2>
<i class="fal fa-stethoscope"></i> Health Plan Details
</h2>
</div>
</div>
<div class="row title-desc">
<div class="col-sm-12"> Please do your best to provide as much information as you can below. While more information will assist the Claims Administrator in processing your claim, only boxes marked with an * are required. </div>
</div>
<div id="health-plan-wrapper-0" class="health-plan-wrapper">
<input autocomplete="off" type="hidden" id="Business.HealthPlanDetails.Index" name="Business.HealthPlanDetails.Index" value="0">
<div class="row sub-title">
<div class="col-sm-12">
<div class="row">
<div class="col-sm-8">
<div class="sub-num">1</div>
<h5 class="health-plan-heading">Health Plan Entry</h5>
</div>
<div class="col-sm-4">
<button type="button" data-service-count="0" class="remove-healthplan-btn btn btn-link float-right" style="display: none"><i class="fa fa-trash"></i> Delete Entry</button>
</div>
</div>
<hr>
</div>
</div>
<div class="row mb-4">
<div class="col-md-6 health-plan-name-form-group">
<label for="business-health-plan-name-select-0" class="control-label required-field-label">Health Plan Name</label>
<select id="business-health-plan-name-select-0" class="health-plan-name-select" style="display: none;">
<option value=""></option>
<option value="Anthem Blue Cross Life and Health Insurance Company">Anthem Blue Cross Life and Health Insurance Company</option>
<option value="Anthem Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Kentucky)">Anthem Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Kentucky)</option>
<option value="Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Maine)">Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Maine)</option>
<option value="Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue Cross and Blue Shield (of New Hampshire)">Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue Cross and Blue Shield (of New Hampshire)</option>
<option value="Anthem Health Plans of Virginia, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Virginia)">Anthem Health Plans of Virginia, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Virginia)</option>
<option value="Anthem Health Plans, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Connecticut)">Anthem Health Plans, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Connecticut)</option>
<option value="Anthem Insurance Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana)">Anthem Insurance Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana)</option>
<option value="Arkansas Blue Cross and Blue Shield">Arkansas Blue Cross and Blue Shield</option>
<option value="Blue Benefits Administrators">Blue Benefits Administrators</option>
<option value="Blue Care Network of Michigan">Blue Care Network of Michigan</option>
<option value="Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company">Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company</option>
<option value="Blue Cross & Blue Shield of Rhode Island">Blue Cross & Blue Shield of Rhode Island</option>
<option value="Blue Cross and Blue Shield of Alabama">Blue Cross and Blue Shield of Alabama</option>
<option value="Blue Cross and Blue Shield of Georgia, Inc.">Blue Cross and Blue Shield of Georgia, Inc.</option>
<option value="Blue Cross and Blue Shield of Illinois">Blue Cross and Blue Shield of Illinois</option>
<option value="Blue Cross and Blue Shield of Kansas">Blue Cross and Blue Shield of Kansas</option>
<option value="Blue Cross and Blue Shield of Kansas City">Blue Cross and Blue Shield of Kansas City</option>
<option value="Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.">Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.</option>
<option value="Blue Cross and Blue Shield of Massachusetts, Inc.">Blue Cross and Blue Shield of Massachusetts, Inc.</option>
<option value="Blue Cross and Blue Shield of Minnesota">Blue Cross and Blue Shield of Minnesota</option>
<option value="Blue Cross and Blue Shield of Montana">Blue Cross and Blue Shield of Montana</option>
<option value="Blue Cross and Blue Shield of New Mexico">Blue Cross and Blue Shield of New Mexico</option>
<option value="Blue Cross and Blue Shield of North Carolina">Blue Cross and Blue Shield of North Carolina</option>
<option value="Blue Cross and Blue Shield of Oklahoma">Blue Cross and Blue Shield of Oklahoma</option>
<option value="Blue Cross and Blue Shield of Texas">Blue Cross and Blue Shield of Texas</option>
<option value="Blue Cross and Blue Shield of Vermont">Blue Cross and Blue Shield of Vermont</option>
<option value="Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a Anthem Blue Cross and Blue Shield">Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Blue Cross Blue Shield of Delaware">Blue Cross Blue Shield of Delaware</option>
<option value="Blue Cross Blue Shield of Louisiana">Blue Cross Blue Shield of Louisiana</option>
<option value="Blue Cross Blue Shield of Massachusetts">Blue Cross Blue Shield of Massachusetts</option>
<option value="Blue Cross Blue Shield of Michigan">Blue Cross Blue Shield of Michigan</option>
<option value="Blue Cross Blue Shield of Nebraska">Blue Cross Blue Shield of Nebraska</option>
<option value="Blue Cross Blue Shield of North Dakota">Blue Cross Blue Shield of North Dakota</option>
<option value="Blue Cross Blue Shield of Northeastern Pennsylvania">Blue Cross Blue Shield of Northeastern Pennsylvania</option>
<option value="Blue Cross Blue Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield">Blue Cross Blue Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Blue Cross Blue Shield of Wyoming">Blue Cross Blue Shield of Wyoming</option>
<option value="Blue Cross of California d/b/a Anthem Blue Cross">Blue Cross of California d/b/a Anthem Blue Cross</option>
<option value="Blue Cross of Idaho">Blue Cross of Idaho</option>
<option value="Blue Plus">Blue Plus</option>
<option value="Blue Shield of California">Blue Shield of California</option>
<option value="Blue Shield of California Life & Health Insurance Company">Blue Shield of California Life & Health Insurance Company</option>
<option value="BlueAdvantage Administrators of Arkansas">BlueAdvantage Administrators of Arkansas</option>
<option value="BlueChoice HealthPlan of South Carolina">BlueChoice HealthPlan of South Carolina</option>
<option value="BlueCross BlueShield of Arizona">BlueCross BlueShield of Arizona</option>
<option value="BlueCross BlueShield of Florida, Inc.">BlueCross BlueShield of Florida, Inc.</option>
<option value="BlueCross BlueShield of South Carolina">BlueCross BlueShield of South Carolina</option>
<option value="BlueCross BlueShield of Tennessee">BlueCross BlueShield of Tennessee</option>
<option value="BlueCross BlueShield of Western New York">BlueCross BlueShield of Western New York</option>
<option value="BlueShield of Northeastern New York">BlueShield of Northeastern New York</option>
<option value="California Physicians’ Service dba Blue Shield of California">California Physicians’ Service dba Blue Shield of California</option>
<option value="Capital Advantage Assurance Company (CAAC)">Capital Advantage Assurance Company (CAAC)</option>
<option value="Capital Advantage Insurance Company (CAIC)">Capital Advantage Insurance Company (CAIC)</option>
<option value="Capital BlueCross">Capital BlueCross</option>
<option value="Capital Health Plan, Inc.">Capital Health Plan, Inc.</option>
<option value="CareFirst BlueChoice, Inc.">CareFirst BlueChoice, Inc.</option>
<option value="CareFirst BlueCross BlueShield DC/Montgomery County/Prince George’s County/Virginia">CareFirst BlueCross BlueShield DC/Montgomery County/Prince George’s County/Virginia</option>
<option value="CareFirst BlueCross BlueShield Maryland">CareFirst BlueCross BlueShield Maryland</option>
<option value="CareFirst of Maryland, Inc. (CFMI)">CareFirst of Maryland, Inc. (CFMI)</option>
<option value="CBA Blue (Vermont)">CBA Blue (Vermont)</option>
<option value="CFA LLC">CFA LLC</option>
<option value="Claim Management Services, Inc. d/b/a Anthem Blue Cross and Blue Shield">Claim Management Services, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Community Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Ohio)">Community Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Ohio)</option>
<option value="Compcare Health Services Insurance Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of Wisconsin)">Compcare Health Services Insurance Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of
Wisconsin)</option>
<option value="Empire HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield">Empire HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield</option>
<option value="Empire HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield">Empire HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield</option>
<option value="Excellus BlueCross BlueShield">Excellus BlueCross BlueShield</option>
<option value="First Priority Health">First Priority Health</option>
<option value="First Priority Life">First Priority Life</option>
<option value="Florida Blue">Florida Blue</option>
<option value="Florida Health Care Plan, Inc.">Florida Health Care Plan, Inc.</option>
<option value="Group Hospitalization and Medical Services, Inc. (GHMSI)">Group Hospitalization and Medical Services, Inc. (GHMSI)</option>
<option value="Hawaii Medical Service Association (HMSA)">Hawaii Medical Service Association (HMSA)</option>
<option value="Health Advantage">Health Advantage</option>
<option value="HealthKeepers, Inc.">HealthKeepers, Inc.</option>
<option value="Healthwise">Healthwise</option>
<option value="Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Missouri)">Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Missouri)</option>
<option value="Highmark Blue Cross Blue Shield">Highmark Blue Cross Blue Shield</option>
<option value="Highmark Blue Cross Blue Shield of Delaware">Highmark Blue Cross Blue Shield of Delaware</option>
<option value="Highmark Blue Cross Blue Shield of West Virginia">Highmark Blue Cross Blue Shield of West Virginia</option>
<option value="Highmark Blue Shield">Highmark Blue Shield</option>
<option value="HMO Colorado, Inc.">HMO Colorado, Inc.</option>
<option value="HMO Colorado, Inc. d/b/a HMO Nevada, Inc.">HMO Colorado, Inc. d/b/a HMO Nevada, Inc.</option>
<option value="HMO Louisiana, Inc.">HMO Louisiana, Inc.</option>
<option value="HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Missouri)">HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Missouri)</option>
<option value="HMO Partners, Inc.">HMO Partners, Inc.</option>
<option value="Horizon Blue Cross Blue Shield of New Jersey">Horizon Blue Cross Blue Shield of New Jersey</option>
<option value="Independence Administrators">Independence Administrators</option>
<option value="Independence Blue Cross">Independence Blue Cross</option>
<option value="Independence Hospital Indemnity Plan">Independence Hospital Indemnity Plan</option>
<option value="Keystone Health Plan Central, Inc. (KHPC)">Keystone Health Plan Central, Inc. (KHPC)</option>
<option value="Keystone Health Plan East">Keystone Health Plan East</option>
<option value="Keystone Health Plan West">Keystone Health Plan West</option>
<option value="Matthew Thornton Health Plan, Inc.">Matthew Thornton Health Plan, Inc.</option>
<option value="Mountain State Blue Cross Blue Shield">Mountain State Blue Cross Blue Shield</option>
<option value="Premera Blue Cross">Premera Blue Cross</option>
<option value="Premera Blue Cross Blue Shield">Premera Blue Cross Blue Shield</option>
<option value="Premera Blue Cross Blue Shield of Alaska">Premera Blue Cross Blue Shield of Alaska</option>
<option value="QCC Insurance Company">QCC Insurance Company</option>
<option value="Regence BlueCross BlueShield of Oregon">Regence BlueCross BlueShield of Oregon</option>
<option value="Regence BlueCross BlueShield of Utah">Regence BlueCross BlueShield of Utah</option>
<option value="Regence BlueShield">Regence BlueShield</option>
<option value="Regence BlueShield of Idaho">Regence BlueShield of Idaho</option>
<option value="Regence Group Administrators">Regence Group Administrators</option>
<option value="Regence Health Maintenance of Oregon">Regence Health Maintenance of Oregon</option>
<option value="Regence HMO Oregon">Regence HMO Oregon</option>
<option value="Regence Life and Health Insurance Company">Regence Life and Health Insurance Company</option>
<option value="Regence ValueCare">Regence ValueCare</option>
<option value="RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross and Blue Shield">RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Colorado)">Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Colorado)
</option>
<option value="Triple-S Management Corp.">Triple-S Management Corp.</option>
<option value="Triple-S Salud, Inc.">Triple-S Salud, Inc.</option>
<option value="USAble Mutual Insurance Company">USAble Mutual Insurance Company</option>
<option value="Wellmark BCBS of Iowa">Wellmark BCBS of Iowa</option>
<option value="Wellmark BCBS of South Dakota">Wellmark BCBS of South Dakota</option>
<option value="Wellmark Health Plan of Iowa">Wellmark Health Plan of Iowa</option>
<option value="Wellmark Synergy Health Plan">Wellmark Synergy Health Plan</option>
<option value="Wellmark Value Health Plan">Wellmark Value Health Plan</option>
<option value="Wisconsin Collaborative Insurance Company">Wisconsin Collaborative Insurance Company</option>
<option value="Other">Other</option>
</select><span class="k-picker-wrap k-state-default"><input title="" class="form-control k-input ui-autocomplete-input"
autocomplete="off"><a tabindex="-1" title="Show All Items" class="fa fa-chevron-down plan-dropdown-selector k-select"></a></span>
<div class="row health-plan-name-other" style="display: none;">
<div class="col-12">
<label for="business-health-plan-name-other-0" class="control-label">Other Health Plan Name</label>
<input id="business-health-plan-name-other-0" autocomplete="off" class="form-control" type="text" maxlength="200">
</div>
</div>
<span class="text-danger field-validation-valid" data-valmsg-replace="true" data-valmsg-for="Business.HealthPlanDetails[0].Name"></span>
<input autocomplete="off" type="text" class="health-plan-name" maxlength="200" tabindex="-1" aria-labelledby="business-health-plan-name-select-0" data-val="true" data-val-maxlength="Plan name must be less than 200 characters."
data-val-maxlength-max="200" data-val-required="This is required." id="Business_HealthPlanDetails_0__Name" name="Business.HealthPlanDetails[0].Name" value="" aria-required="true">
</div>
<div class="col-md-6">
<label class="control-label" for="Business_HealthPlanDetails_0__GroupNumber">Group #</label>
<input autocomplete="off" type="text" class="form-control group-number" maxlength="100" id="Business_HealthPlanDetails_0__GroupNumber" name="Business.HealthPlanDetails[0].GroupNumber" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Business.HealthPlanDetails[0].GroupNumber" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6">
<label class="control-label start-date-label" for="Business_HealthPlanDetails_0__CoverageStartDate">Coverage Start Date</label>
<span class="k-widget k-datepicker form-control coverageStartDate" style=""><span class="k-picker-wrap k-state-default"><input autocomplete="off" type="text" class="form-control coverageStartDate k-input" value=""
placeholder="MM/YYYY" id="Business_HealthPlanDetails_0__CoverageStartDate" name="Business.HealthPlanDetails[0].CoverageStartDate" data-role="datepicker" role="combobox" aria-expanded="false"
aria-owns="Business_HealthPlanDetails_0__CoverageStartDate_dateview" aria-disabled="false" style="width: 100%;"><span class="k-icon k-i-warning"></span><span unselectable="on" class="k-select" aria-label="select"
role="button" aria-controls="Business_HealthPlanDetails_0__CoverageStartDate_dateview"><span class="k-icon k-i-calendar"></span></span></span></span>
<span class="text-danger field-validation-valid" data-valmsg-for="Business.HealthPlanDetails[0].CoverageStartDate" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6">
<label class="control-label" for="Business_HealthPlanDetails_0__CoverageEndDate">Coverage End Date</label>
<span class="k-widget k-datepicker form-control coverageEndDate" style=""><span class="k-picker-wrap k-state-default"><input autocomplete="off" type="text" class="form-control coverageEndDate k-input" value=""
placeholder="MM/YYYY" id="Business_HealthPlanDetails_0__CoverageEndDate" name="Business.HealthPlanDetails[0].CoverageEndDate" data-role="datepicker" role="combobox" aria-expanded="false"
aria-owns="Business_HealthPlanDetails_0__CoverageEndDate_dateview" aria-disabled="false" style="width: 100%;"><span class="k-icon k-i-warning"></span><span unselectable="on" class="k-select" aria-label="select" role="button"
aria-controls="Business_HealthPlanDetails_0__CoverageEndDate_dateview"><span class="k-icon k-i-calendar"></span></span></span></span>
<span class="text-danger field-validation-valid" data-valmsg-for="Business.HealthPlanDetails[0].CoverageEndDate" data-valmsg-replace="true"></span>
</div>
</div>
<div class="throughEntityWrapper">
<fieldset>
<div class="row mb-2">
<div class="col-xl-7">
<label class="control-label required-field-label mr-4"> Was this plan purchased through a <a data-html="true" data-toggle="popover" title="" data-content="You purchased this plan through a Purchasing Entity if: (1) your company/business/entity acquired its health plan through another purchasing entity, such as a Professional Employer Organization ("PEO") or (2) you are a PEO, Union or Trade Association, or other associational entity that collected payment for, contracted with or purchased a BCBS health insurance or administrative services plan on behalf of your client companies, customers or members directly from a BCBS company." data-trigger="manual" tabindex="0" data-original-title="<i class='fa fa-info-circle'></i> Purchasing Entity">
Purchasing Entity
<i class="fa fa-info-circle"></i>
</a> ? </label>
</div>
<div class="col-xl-5">
<span class="mr-2">
<label>
<input autocomplete="off" id="Business_HealthPlanDetails_0__PurchasedThroughEntity_Yes" value="true" type="radio" class="throughEntityRadio throughEntityRadioYes" data-val="true" data-val-required="This is required."
name="Business.HealthPlanDetails[0].PurchasedThroughEntity" aria-required="true"> Yes </label>
</span>
<span>
<label>
<input autocomplete="off" id="Business_HealthPlanDetails_0__PurchasedThroughEntity_No" value="false" type="radio" class="throughEntityRadio" name="Business.HealthPlanDetails[0].PurchasedThroughEntity" aria-required="true">
No </label>
</span>
<span class="text-danger field-validation-valid" data-valmsg-for="Business.HealthPlanDetails[0].PurchasedThroughEntity" data-valmsg-replace="true"></span>
</div>
</div>
</fieldset>
<div class="entityDetails" style="display: none">
<div class="row mb-2">
<div class="col-md-12">
<div class="alert alert-secondary">
<div class="row">
<div class="col-sm-1" style="max-width: 20px;">
<input type="checkbox" class="acquiredThroughChb" data-val="true"
data-val-required="The Check this box if your company/business/entity acquired its health plan through another purchasing entity, such as a Professional Employer Organization ("PEO"). field is required."
id="Business_HealthPlanDetails_0__AcquiredThroughAnotherEntity" name="Business.HealthPlanDetails[0].AcquiredThroughAnotherEntity" value="true">
<span class="text-danger field-validation-valid" data-valmsg-for="Business.HealthPlanDetails[0].AcquiredThroughAnotherEntity" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-11">
<label class="control-label required-field-label" for="Business_HealthPlanDetails_0__AcquiredThroughAnotherEntity">Check this box if your company/business/entity acquired its health plan through another purchasing
entity, such as a Professional Employer Organization ("PEO").</label>
</div>
</div>
</div>
</div>
</div>
<div class="row purchaseEntityTxt mb-2" style="display: none">
<div class="col-md-12">
<div class="form-inline">
<label class="control-label required-field-label" for="Business_HealthPlanDetails_0__PurchasingEntity">Purchasing Entity</label>
<input autocomplete="off" type="text" class="form-control purchasing-entity" maxlength="100" data-val="true" data-val-requiredif="The field Purchasing Entity is invalid." data-val-requiredif-comp="isequalto"
data-val-requiredif-other="AcquiredThroughAnotherEntity" data-val-requiredif-value="True" id="Business_HealthPlanDetails_0__PurchasingEntity" name="Business.HealthPlanDetails[0].PurchasingEntity" value="">
</div>
<span class="text-danger field-validation-valid" data-valmsg-for="Business.HealthPlanDetails[0].PurchasingEntity" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div class="alert alert-secondary">
<div class="row">
<div class="col-sm-1" style="max-width: 20px;">
<input autocomplete="off" class="onBehalfOfOthersChb" type="checkbox" data-val="true"
data-val-required="The Check this box if you are a PEO, Union, Trade Association, or other associational entity that collected payment for, contracted with or purchased a BCBS health insurance or administrative services plan on behalf of your client companies, customers or members directly from a BCBS company. field is required."
id="Business_HealthPlanDetails_0__ServicesOnBehalfOfOthers" name="Business.HealthPlanDetails[0].ServicesOnBehalfOfOthers" value="true">
<span class="text-danger field-validation-valid" data-valmsg-for="Business.HealthPlanDetails[0].ServicesOnBehalfOfOthers" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-11">
<label class="control-label required-field-label" for="Business_HealthPlanDetails_0__ServicesOnBehalfOfOthers">Check this box if you are a PEO, Union, Trade Association, or other associational entity that collected
payment for, contracted with or purchased a BCBS health insurance or administrative services plan on behalf of your client companies, customers or members directly from a BCBS company.</label>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="text-center">
<button type="button" class="show-more-link btn btn-link" style="display: none">Show More…</button>
<button type="button" class="show-less-link btn btn-link" style="display: none">Show Less…</button>
</div>
</div>
</div>
</div>
</div>
<hr>
<div class="alert alert-danger" role="alert" id="groupNrRequiredErrMsg" style="display: none">
<i class="fa fa-exclamation-circle"></i> Group # field is required.
</div>
<div class="alert alert-danger" role="alert" id="coverageStartDateRequiredErrMsg" style="display: none">
<i class="fa fa-exclamation-circle"></i> LocKey_CoverageStartDateRequiredErrMsgRequiredErrMsg
</div>
<div class="alert alert-danger" role="alert" id="coverageEndDateRequiredErrMsg" style="display: none">
<i class="fa fa-exclamation-circle"></i> LocKey_CoverageEndDateRequiredErrMsgRequiredErrMsg
</div>
<button type="button" class="add-healthplan-btn btn btn-primary-outline"><i class="fa fa-plus-square"></i> Add another Health Plan</button>
</div>
</div>
<div class="add-healthplan-template hidden">
<div id="health-plan-wrapper-{count}" class="health-plan-wrapper-hidden">
<div class="row sub-title">
<div class="col-sm-12">
<div class="row">
<div class="col-sm-8">
<div class="sub-num"></div>
<h5 class="health-plan-heading">Health Plan Entry</h5>
</div>
<div class="col-sm-4">
<button type="button" data-service-count="{count}" class="remove-healthplan-btn btn btn-link float-right"><i class="fa fa-trash"></i> Delete Entry</button>
</div>
</div>
<hr>
</div>
</div>
<div class="row mb-4">
<div class="col-md-6 health-plan-name-form-group">
<label for="business-health-plan-name-select-{count}" class="control-label required-field-label">Health Plan Name</label>
<select id="business-health-plan-name-select-{count}" class="health-plan-name-select">
<option value=""></option>
<option value="Anthem Blue Cross Life and Health Insurance Company">Anthem Blue Cross Life and Health Insurance Company</option>
<option value="Anthem Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Kentucky)">Anthem Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Kentucky)</option>
<option value="Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Maine)">Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Maine)</option>
<option value="Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue Cross and Blue Shield (of New Hampshire)">Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue Cross and Blue Shield (of New Hampshire)</option>
<option value="Anthem Health Plans of Virginia, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Virginia)">Anthem Health Plans of Virginia, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Virginia)</option>
<option value="Anthem Health Plans, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Connecticut)">Anthem Health Plans, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Connecticut)</option>
<option value="Anthem Insurance Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana)">Anthem Insurance Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana)</option>
<option value="Arkansas Blue Cross and Blue Shield">Arkansas Blue Cross and Blue Shield</option>
<option value="Blue Benefits Administrators">Blue Benefits Administrators</option>
<option value="Blue Care Network of Michigan">Blue Care Network of Michigan</option>
<option value="Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company">Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company</option>
<option value="Blue Cross & Blue Shield of Rhode Island">Blue Cross & Blue Shield of Rhode Island</option>
<option value="Blue Cross and Blue Shield of Alabama">Blue Cross and Blue Shield of Alabama</option>
<option value="Blue Cross and Blue Shield of Georgia, Inc.">Blue Cross and Blue Shield of Georgia, Inc.</option>
<option value="Blue Cross and Blue Shield of Illinois">Blue Cross and Blue Shield of Illinois</option>
<option value="Blue Cross and Blue Shield of Kansas">Blue Cross and Blue Shield of Kansas</option>
<option value="Blue Cross and Blue Shield of Kansas City">Blue Cross and Blue Shield of Kansas City</option>
<option value="Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.">Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.</option>
<option value="Blue Cross and Blue Shield of Massachusetts, Inc.">Blue Cross and Blue Shield of Massachusetts, Inc.</option>
<option value="Blue Cross and Blue Shield of Minnesota">Blue Cross and Blue Shield of Minnesota</option>
<option value="Blue Cross and Blue Shield of Montana">Blue Cross and Blue Shield of Montana</option>
<option value="Blue Cross and Blue Shield of New Mexico">Blue Cross and Blue Shield of New Mexico</option>
<option value="Blue Cross and Blue Shield of North Carolina">Blue Cross and Blue Shield of North Carolina</option>
<option value="Blue Cross and Blue Shield of Oklahoma">Blue Cross and Blue Shield of Oklahoma</option>
<option value="Blue Cross and Blue Shield of Texas">Blue Cross and Blue Shield of Texas</option>
<option value="Blue Cross and Blue Shield of Vermont">Blue Cross and Blue Shield of Vermont</option>
<option value="Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a Anthem Blue Cross and Blue Shield">Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Blue Cross Blue Shield of Delaware">Blue Cross Blue Shield of Delaware</option>
<option value="Blue Cross Blue Shield of Louisiana">Blue Cross Blue Shield of Louisiana</option>
<option value="Blue Cross Blue Shield of Massachusetts">Blue Cross Blue Shield of Massachusetts</option>
<option value="Blue Cross Blue Shield of Michigan">Blue Cross Blue Shield of Michigan</option>
<option value="Blue Cross Blue Shield of Nebraska">Blue Cross Blue Shield of Nebraska</option>
<option value="Blue Cross Blue Shield of North Dakota">Blue Cross Blue Shield of North Dakota</option>
<option value="Blue Cross Blue Shield of Northeastern Pennsylvania">Blue Cross Blue Shield of Northeastern Pennsylvania</option>
<option value="Blue Cross Blue Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield">Blue Cross Blue Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Blue Cross Blue Shield of Wyoming">Blue Cross Blue Shield of Wyoming</option>
<option value="Blue Cross of California d/b/a Anthem Blue Cross">Blue Cross of California d/b/a Anthem Blue Cross</option>
<option value="Blue Cross of Idaho">Blue Cross of Idaho</option>
<option value="Blue Plus">Blue Plus</option>
<option value="Blue Shield of California">Blue Shield of California</option>
<option value="Blue Shield of California Life & Health Insurance Company">Blue Shield of California Life & Health Insurance Company</option>
<option value="BlueAdvantage Administrators of Arkansas">BlueAdvantage Administrators of Arkansas</option>
<option value="BlueChoice HealthPlan of South Carolina">BlueChoice HealthPlan of South Carolina</option>
<option value="BlueCross BlueShield of Arizona">BlueCross BlueShield of Arizona</option>
<option value="BlueCross BlueShield of Florida, Inc.">BlueCross BlueShield of Florida, Inc.</option>
<option value="BlueCross BlueShield of South Carolina">BlueCross BlueShield of South Carolina</option>
<option value="BlueCross BlueShield of Tennessee">BlueCross BlueShield of Tennessee</option>
<option value="BlueCross BlueShield of Western New York">BlueCross BlueShield of Western New York</option>
<option value="BlueShield of Northeastern New York">BlueShield of Northeastern New York</option>
<option value="California Physicians’ Service dba Blue Shield of California">California Physicians’ Service dba Blue Shield of California</option>
<option value="Capital Advantage Assurance Company (CAAC)">Capital Advantage Assurance Company (CAAC)</option>
<option value="Capital Advantage Insurance Company (CAIC)">Capital Advantage Insurance Company (CAIC)</option>
<option value="Capital BlueCross">Capital BlueCross</option>
<option value="Capital Health Plan, Inc.">Capital Health Plan, Inc.</option>
<option value="CareFirst BlueChoice, Inc.">CareFirst BlueChoice, Inc.</option>
<option value="CareFirst BlueCross BlueShield DC/Montgomery County/Prince George’s County/Virginia">CareFirst BlueCross BlueShield DC/Montgomery County/Prince George’s County/Virginia</option>
<option value="CareFirst BlueCross BlueShield Maryland">CareFirst BlueCross BlueShield Maryland</option>
<option value="CareFirst of Maryland, Inc. (CFMI)">CareFirst of Maryland, Inc. (CFMI)</option>
<option value="CBA Blue (Vermont)">CBA Blue (Vermont)</option>
<option value="CFA LLC">CFA LLC</option>
<option value="Claim Management Services, Inc. d/b/a Anthem Blue Cross and Blue Shield">Claim Management Services, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Community Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Ohio)">Community Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Ohio)</option>
<option value="Compcare Health Services Insurance Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of Wisconsin)">Compcare Health Services Insurance Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of
Wisconsin)</option>
<option value="Empire HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield">Empire HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield</option>
<option value="Empire HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield">Empire HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield</option>
<option value="Excellus BlueCross BlueShield">Excellus BlueCross BlueShield</option>
<option value="First Priority Health">First Priority Health</option>
<option value="First Priority Life">First Priority Life</option>
<option value="Florida Blue">Florida Blue</option>
<option value="Florida Health Care Plan, Inc.">Florida Health Care Plan, Inc.</option>
<option value="Group Hospitalization and Medical Services, Inc. (GHMSI)">Group Hospitalization and Medical Services, Inc. (GHMSI)</option>
<option value="Hawaii Medical Service Association (HMSA)">Hawaii Medical Service Association (HMSA)</option>
<option value="Health Advantage">Health Advantage</option>
<option value="HealthKeepers, Inc.">HealthKeepers, Inc.</option>
<option value="Healthwise">Healthwise</option>
<option value="Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Missouri)">Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Missouri)</option>
<option value="Highmark Blue Cross Blue Shield">Highmark Blue Cross Blue Shield</option>
<option value="Highmark Blue Cross Blue Shield of Delaware">Highmark Blue Cross Blue Shield of Delaware</option>
<option value="Highmark Blue Cross Blue Shield of West Virginia">Highmark Blue Cross Blue Shield of West Virginia</option>
<option value="Highmark Blue Shield">Highmark Blue Shield</option>
<option value="HMO Colorado, Inc.">HMO Colorado, Inc.</option>
<option value="HMO Colorado, Inc. d/b/a HMO Nevada, Inc.">HMO Colorado, Inc. d/b/a HMO Nevada, Inc.</option>
<option value="HMO Louisiana, Inc.">HMO Louisiana, Inc.</option>
<option value="HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Missouri)">HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Missouri)</option>
<option value="HMO Partners, Inc.">HMO Partners, Inc.</option>
<option value="Horizon Blue Cross Blue Shield of New Jersey">Horizon Blue Cross Blue Shield of New Jersey</option>
<option value="Independence Administrators">Independence Administrators</option>
<option value="Independence Blue Cross">Independence Blue Cross</option>
<option value="Independence Hospital Indemnity Plan">Independence Hospital Indemnity Plan</option>
<option value="Keystone Health Plan Central, Inc. (KHPC)">Keystone Health Plan Central, Inc. (KHPC)</option>
<option value="Keystone Health Plan East">Keystone Health Plan East</option>
<option value="Keystone Health Plan West">Keystone Health Plan West</option>
<option value="Matthew Thornton Health Plan, Inc.">Matthew Thornton Health Plan, Inc.</option>
<option value="Mountain State Blue Cross Blue Shield">Mountain State Blue Cross Blue Shield</option>
<option value="Premera Blue Cross">Premera Blue Cross</option>
<option value="Premera Blue Cross Blue Shield">Premera Blue Cross Blue Shield</option>
<option value="Premera Blue Cross Blue Shield of Alaska">Premera Blue Cross Blue Shield of Alaska</option>
<option value="QCC Insurance Company">QCC Insurance Company</option>
<option value="Regence BlueCross BlueShield of Oregon">Regence BlueCross BlueShield of Oregon</option>
<option value="Regence BlueCross BlueShield of Utah">Regence BlueCross BlueShield of Utah</option>
<option value="Regence BlueShield">Regence BlueShield</option>
<option value="Regence BlueShield of Idaho">Regence BlueShield of Idaho</option>
<option value="Regence Group Administrators">Regence Group Administrators</option>
<option value="Regence Health Maintenance of Oregon">Regence Health Maintenance of Oregon</option>
<option value="Regence HMO Oregon">Regence HMO Oregon</option>
<option value="Regence Life and Health Insurance Company">Regence Life and Health Insurance Company</option>
<option value="Regence ValueCare">Regence ValueCare</option>
<option value="RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross and Blue Shield">RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Colorado)">Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Colorado)
</option>
<option value="Triple-S Management Corp.">Triple-S Management Corp.</option>
<option value="Triple-S Salud, Inc.">Triple-S Salud, Inc.</option>
<option value="USAble Mutual Insurance Company">USAble Mutual Insurance Company</option>
<option value="Wellmark BCBS of Iowa">Wellmark BCBS of Iowa</option>
<option value="Wellmark BCBS of South Dakota">Wellmark BCBS of South Dakota</option>
<option value="Wellmark Health Plan of Iowa">Wellmark Health Plan of Iowa</option>
<option value="Wellmark Synergy Health Plan">Wellmark Synergy Health Plan</option>
<option value="Wellmark Value Health Plan">Wellmark Value Health Plan</option>
<option value="Wisconsin Collaborative Insurance Company">Wisconsin Collaborative Insurance Company</option>
<option value="Other">Other</option>
</select>
<div class="row health-plan-name-other" style="display: none;">
<div class="col-12">
<label for="business-health-plan-name-other-{count}" class="control-label">Other Health Plan Name</label>
<input id="business-health-plan-name-other-{count}" autocomplete="off" class="form-control" type="text" maxlength="200">
</div>
</div>
<span data-valmsg-for="Business.HealthPlanDetails[{count}].Name" class="text-danger" data-valmsg-replace="true"></span>
<input autocomplete="off" type="text" name="Business.HealthPlanDetails[{count}].Name" class="health-plan-name" maxlength="200" tabindex="-1" aria-labelledby="business-health-plan-name-select-{count}">
</div>
<div class="col-md-6">
<label class="control-label">Group #</label>
<input autocomplete="off" type="text" name="Business.HealthPlanDetails[{count}].GroupNumber" class="form-control group-number" maxlength="100">
<span data-valmsg-for="Business.HealthPlanDetails[{count}].GroupNumber" class="text-danger" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6">
<label class="control-label start-date-label">Coverage Start Date</label>
<input autocomplete="off" type="date" name="Business.HealthPlanDetails[{count}].CoverageStartDate" class="form-control coverageStartDate" value="" placeholder="MM/YYYY">
<span data-valmsg-for="Business.HealthPlanDetails[{count}].CoverageStartDate" class="text-danger" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6">
<label class="control-label">Coverage End Date</label>
<input autocomplete="off" type="date" name="Business.HealthPlanDetails[{count}].CoverageEndDate" class="form-control coverageEndDate" value="" placeholder="MM/YYYY">
<span data-valmsg-for="Business.HealthPlanDetails[{count}].CoverageEndDate" class="text-danger" data-valmsg-replace="true"></span>
</div>
</div>
<div class="throughEntityWrapper">
<fieldset>
<div class="row mb-2">
<div class="col-xl-7">
<label class="control-label required-field-label mr-4"> Was this plan purchased through a <a data-html="true" data-toggle="popover" title="" data-content="You purchased this plan through a Purchasing Entity if: (1) your company/business/entity acquired its health plan through another purchasing entity, such as a Professional Employer Organization ("PEO") or (2) you are a PEO, Union or Trade Association, or other associational entity that collected payment for, contracted with or purchased a BCBS health insurance or administrative services plan on behalf of your client companies, customers or members directly from a BCBS company." data-trigger="manual" tabindex="0" data-original-title="<i class='fa fa-info-circle'></i> Purchasing Entity">
Purchasing Entity
<i class="fa fa-info-circle"></i>
</a> ? </label>
</div>
<div class="col-xl-5">
<span class="mr-2">
<label>
<input autocomplete="off" name="Business.HealthPlanDetails[{count}].PurchasedThroughEntity" id="Business_HealthPlanDetails_{count}__PurchasedThroughEntity_Yes" value="true" type="radio"
class="throughEntityRadio throughEntityRadioYes"> Yes </label>
</span>
<span>
<label>
<input autocomplete="off" name="Business.HealthPlanDetails[{count}].PurchasedThroughEntity" id="Business_HealthPlanDetails_{count}__PurchasedThroughEntity_No" value="false" type="radio" class="throughEntityRadio"> No
</label>
</span>
<span data-valmsg-for="Business.HealthPlanDetails[{count}].PurchasedThroughEntity" class="text-danger" data-valmsg-replace="true"></span>
</div>
</div>
</fieldset>
<div class="entityDetails" style="display: none">
<div class="row mb-2">
<div class="col-md-12">
<div class="alert alert-secondary">
<div class="row">
<div class="col-sm-1" style="max-width: 20px;">
<input type="checkbox" value="true" name="Business.HealthPlanDetails[{count}].AcquiredThroughAnotherEntity" id="Business_HealthPlanDetails_{count}__AcquiredThroughAnotherEntity" class="acquiredThroughChb">
<span data-valmsg-for="Business.HealthPlanDetails[{count}].AcquiredThroughAnotherEntity" class="text-danger" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-11">
<label class="control-label required-field-label" for="Business_HealthPlanDetails_{count}__AcquiredThroughAnotherEntity">Check this box if your company/business/entity acquired its health plan through another purchasing
entity, such as a Professional Employer Organization ("PEO").</label>
</div>
</div>
</div>
</div>
</div>
<div class="row purchaseEntityTxt mb-2" style="display: none">
<div class="col-md-12">
<div class="form-inline">
<label class="control-label required-field-label" for="Business_HealthPlanDetails_{count}__PurchasingEntity">Purchasing Entity</label>
<input autocomplete="off" type="text" name="Business.HealthPlanDetails[{count}].PurchasingEntity" id="Business_HealthPlanDetails_{count}__PurchasingEntity" class="form-control purchasing-entity" maxlength="100">
</div>
<span data-valmsg-for="Business.HealthPlanDetails[{count}].PurchasingEntity" class="text-danger" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div class="alert alert-secondary">
<div class="row">
<div class="col-sm-1" style="max-width: 20px;">
<input type="checkbox" value="true" name="Business.HealthPlanDetails[{count}].ServicesOnBehalfOfOthers" id="Business_HealthPlanDetails_{count}__ServicesOnBehalfOfOthers" class="onBehalfOfOthersChb">
<span data-valmsg-for="Business.HealthPlanDetails[{count}].ServicesOnBehalfOfOthers" class="text-danger" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-11">
<label class="control-label required-field-label" for="Business_HealthPlanDetails_{count}__ServicesOnBehalfOfOthers">Check this box if you are a PEO, Union, Trade Association, or other associational entity that collected
payment for, contracted with or purchased a BCBS health insurance or administrative services plan on behalf of your client companies, customers or members directly from a BCBS company.</label>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="text-center">
<button type="button" class="show-more-link btn btn-link" style="display: none">Show More…</button>
<button type="button" class="show-less-link btn btn-link" style="display: none">Show Less…</button>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<!-- SECTION 13. -->
<section id="option1section13" class="datalosswarning-on allocation-of-premiums-section">
<div class="allocation-of-premiums-introduction question-group">
<div class="row title-icon">
<div class="col-sm-12">
<h2>
<i class="fal fa-file-contract"></i> Allocation of Premiums
</h2>
</div>
</div>
<div class="row title-desc">
<div class="col-sm-12">
<p> The Settlement provides that payments will be based, in part, on premiums paid for BCBS health insurance or administrative services plans during the relevant periods between February 2008 and October 2020 for fully insured plans,
and between September 2015 and October 2020 for administrative services plans. </p>
<p>The Settlement further provides default formulas for the Claims Administrator to use when determining what percentage of the premium was paid by an employer/entity and what percentage was contributed by its employees/members.</p>
<p> If you accept the <a data-html="true" data-toggle="popover" title="" data-content="100% of premiums for employees who do not file claims are allocated to the claiming employer. When an employee does claim, their premium share is determined through the default formulas, which provide that employees with single coverage are allocated 15% (for fully-insured health insurance) or 18% (for administrative plans) of the total premium paid on their behalf by their employer, and employees with family coverage are allocated 34% (for fully-insured health insurance) or 25% (for administrative plans), with the remainder allocated to the employer. For a full discussion of how these formulas will be used in calculating claims, please refer to the <a href="https://www.bcbssettlement.com/admin/services/connectedapps.cms.extensions/1.0.0.0/asset?id=4a81c01d-f915-4cc4-bec8-3df1d1dda5c5&languageId=1033&inline=true" target="_blank">Plan of Distribution</a> on the Settlement Website." data-trigger="manual" tabindex="0" data-original-title="<i class="fa fa-info-circle"></i> Default Option">
Default option
<i class="fa fa-info-circle"></i>
</a> , you are <b>NOT</b> required to provide any additional data or evidence in support of your claim at this time. If another claimant’s filing affects your claim, you will be provided with an opportunity to respond at a later
date. </p>
<p> If you proceed with the <a data-html="true" data-toggle="popover" title="" data-content="Selecting the alternative option requires that you provide the percentage contribution you believe you contributed for each year that you were enrolled in a BCBS health insurance or administrative services plan. If you choose to apply for an alternative contribution percentage you must supply documentation with this claim form supporting the percentage you claim to have contributed. For a full discussion of how these formulas will be used in calculating claims, please refer to the <a href="https://www.bcbssettlement.com/admin/services/connectedapps.cms.extensions/1.0.0.0/asset?id=4a81c01d-f915-4cc4-bec8-3df1d1dda5c5&languageId=1033&inline=true" target="_blank">Plan of Distribution</a> on the Settlement Website." data-trigger="manual" tabindex="0" data-original-title="<i class="fa fa-info-circle"></i> Alternative Option">
Alternative option
<i class="fa fa-info-circle"></i>
</a> , you must also provide data or evidence to support the alternative contribution percentages you provide. If you select this option, for any time period for which supporting data or evidence is not provided, the Default Option
will be applied. </p>
</div>
</div>
</div>
<div class="allocation-of-premiums-decision question-group">
<input autocomplete="off" type="hidden" value="true" data-val="true" data-val-required="This is required." id="Business_AllocationOfPremiums_HasAcceptedDefaultAllocationOption"
name="Business.AllocationOfPremiums.HasAcceptedDefaultAllocationOption">
<div class="allocation-options row">
<div class="col-lg-6">
<div class="allocation-option selected-allocation-option" data-accept-default-allocation="true" tabindex="0">
<div class="wrapper">
<h3>Accept the Default Option</h3>
<div class="icon"><i class="fal fa-check-circle"></i></div>
</div>
</div>
</div>
<div class="col-lg-6">
<div class="allocation-option" data-accept-default-allocation="false" data-toggle="modal" data-target="#business-flow .alternative-contribution-warning" tabindex="0">
<div class="wrapper">
<h3>Apply for an Alternative Contribution %</h3>
<div class="icon"><i class="fal fa-file-alt"></i></div>
</div>
</div>
</div>
</div>
</div>
<div class="allocation-of-premiums-alternative" style="display:none;">
<div class="row">
<div class="col-md-12">
<div class="default-option-cta">
<div class="row">
<div class="col-md-12">
<div class="wrapper">
<div class="icon">
<div class="circle">
<img src="https://www.bcbssettlement.com/shk/ocf/images/stop-sign.png" alt="Stop Sign">
</div>
</div>
<div class="text">
<p>
<span class="double-underline"><span class="lines"></span><b>STOP:</b></span>
<b>If you want to use the DEFAULT OPTION,</b>
<span class="double-underline"><span class="lines"></span><b>DO NOT</b></span>
<b>FILL OUT THIS SECTION. Instead, click</b>
<a class="allocation-option" data-accept-default-allocation="true" data-dismiss="modal">
<u>HERE</u>.
</a>
</p>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row sub-title">
<div class="col-sm-12">
<div class="sub-num">1</div>
<h5>Alternative Option</h5>
<hr>
</div>
</div>
<div class="row title-desc">
<div class="col-sm-12">
<p> Please state the percentage contribution you believe you contributed for each year that you were enrolled in a BCBS health insurance or administrative services plan. </p>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="allocation-of-premiums-contributions">
<div class="row">
<div class="col-6 col-sm-3">
<label id="business-allocation-year-header" class="required-field-label">Plan Year</label>
</div>
<div class="col-6 col-sm-5">
<label id="business-allocation-contribution-header" class="required-field-label">Contribution</label>
</div>
</div>
<hr>
<div id="business-allocation-of-premiums-contributions-wrapper-0" class="allocation-of-premiums-contributions-wrapper">
<input autocomplete="off" type="hidden" id="Business.AllocationOfPremiums.AllocationOfPremiumsContributions.Index" name="Business.AllocationOfPremiums.AllocationOfPremiumsContributions.Index" value="0">
<div class="row mb-2">
<div class="col-6 col-sm-3">
<select class="year form-control" aria-labelledby="business-allocation-year-header" data-val="true" data-val-range="Invalid Year." data-val-range-max="2020" data-val-range-min="2008"
id="Business_AllocationOfPremiums_AllocationOfPremiumsContributions_0__Year" name="Business.AllocationOfPremiums.AllocationOfPremiumsContributions[0].Year" aria-required="true">
<option value=""></option>
<option>2008</option>
<option>2009</option>
<option>2010</option>
<option>2011</option>
<option>2012</option>
<option>2013</option>
<option>2014</option>
<option>2015</option>
<option>2016</option>
<option>2017</option>
<option>2018</option>
<option>2019</option>
<option>2020</option>
</select><span class="text-danger text-wrap field-validation-valid" data-valmsg-for="Business.AllocationOfPremiums.AllocationOfPremiumsContributions[0].Year" data-valmsg-replace="true"></span>
</div>
<div class="col-6 col-sm-5">
<input autocomplete="off" style="display:inline; width:80%;" type="text" class="allocation-contribution-percent percent form-control" aria-labelledby="business-allocation-contribution-header" data-val="true"
data-val-number="The field ContributionPercent must be a number." id="Business_AllocationOfPremiums_AllocationOfPremiumsContributions_0__ContributionPercent"
name="Business.AllocationOfPremiums.AllocationOfPremiumsContributions[0].ContributionPercent" value="" aria-required="true">
<div style="display:inline;">%</div>
<span class="text-danger text-wrap field-validation-valid" data-valmsg-for="Business.AllocationOfPremiums.AllocationOfPremiumsContributions[0].ContributionPercent" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-4"></div>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<button type="button" class="add-allocations-of-premiums-year btn btn-primary-outline"><i class="fa fa-plus"></i>ADD ANOTHER YEAR</button>
</div>
</div>
</div>
</div>
</div>
<div class="row sub-title">
<div class="col-sm-12">
<div class="sub-num">2</div>
<h5 id="business-flow-alternative-allocation-supporting-docs-header" class="alternative-allocation-supporting-docs-header">Upload Supporting Documentation</h5>
<hr>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<p> If you choose to apply for an alternative contribution percentage you must supply documentation with this claim form supporting the percentage you claim to have contributed. If you do not submit supporting documentation the
Default contribution rates will be applied to your claim. </p>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="alert alert-secondary">
<label><input type="checkbox" class="mr-2" data-val="true" data-val-required="You must upload documents now or check the box if you will provide documents later."
id="Business_AllocationOfPremiums_UploadAlternativeAllocationOfPremiumsDocsLater" name="Business.AllocationOfPremiums.UploadAlternativeAllocationOfPremiumsDocsLater" value="true"> Check this box if you want to upload your
documents later. </label>
</div>
<span class="text-danger field-validation-valid" data-valmsg-for="Business.AllocationOfPremiums.UploadAlternativeAllocationOfPremiumsDocsLater" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="supporting-documents-allocation-of-premiums">
<div class="row mb-2">
<div class="col-sm-12">
<p class="text-grey">Supported files include: .jpg, .jpeg, .pdf, .png, .tif, and .tiff. Maximum upload size is 10MB</p>
</div>
</div>
<div id="business-allocation-of-premiums-file-inputs-0" class="allocation-of-premiums-file-inputs">
<div class="row">
<div class="col-sm-8">
<input type="file" accept=".jpg, .png, .jpeg, .pdf, .tif, .tiff" style="overflow: hidden" class="form-control allocation-of-premiums-input-file" id="business-allocation-of-premiums-doc_0"
name="business.AllocationOfPremiumsDoc_0" aria-labelledby="business-flow-alternative-allocation-supporting-docs-header">
<span data-valmsg-for="business.AllocationOfPremiumsDoc_0" class="text-danger" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-4">
<a class="clearFileInput"><i class="fa fa-trash"></i> DELETE FILE</a>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<button type="button" class="add-row-allocation-of-premiums-doc btn btn-primary-outline"><i class="fa fa-plus"></i>ADD ANOTHER FILE</button>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="alternative-contribution-warning modal fade" tabindex="-1" role="dialog" aria-labelledby="alternative-contribution-warning-title">
<div class="modal-dialog" role="document">
<div class="modal-content">
<div class="modal-header">
<h3 class="modal-title" id="alternative-contribution-warning-title">
<i class="fal fa-info-circle"></i> Alternative Contribution
</h3>
<button type="button" class="close" data-dismiss="modal" aria-label="Close">
<span aria-hidden="true">×</span>
</button>
</div>
<div class="modal-body">
<p>If you choose to apply for an alternative contribution percentage, you must supply documentation with this claim form supporting the percentage you claim to have contributed. If you do not provide additional documentation, the
Default Option will be applied to your claim.</p>
<p>Selection of the Alternative Option does not ensure a contribution percentage higher than or equal to the Default Option. Your percentage will be dependent on a process that includes a review of all materials submitted pertaining
to your premium.</p>
<p>Are you sure you want to apply for an alternative contribution percentage?</p>
</div>
<div class="modal-footer">
<div class="row mb-2">
<div class="col-sm-12">
<button type="button" class="btn btn-primary-outline allocation-option" data-accept-default-allocation="false" data-dismiss="modal">
<i class="far fa-file-alt"></i>
<span> Continue with alternative option </span>
</button>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<button type="button" class="btn btn-primary allocation-option" data-accept-default-allocation="true" data-dismiss="modal">
<i class="far fa-check-circle"></i>
<span> Switch to the default option </span>
</button>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="add-contribution-template hidden">
<div id="business-allocation-of-premiums-contributions-wrapper-{count}" class="allocation-of-premiums-contributions-wrapper-hidden">
<div class="row mb-2">
<div class="col-6 col-sm-3">
<select name="Business.AllocationOfPremiums.AllocationOfPremiumsContributions[{count}].Year" class="year form-control" aria-labelledby="allocation-year-header">
<option value=""></option>
<option>2008</option>
<option>2009</option>
<option>2010</option>
<option>2011</option>
<option>2012</option>
<option>2013</option>
<option>2014</option>
<option>2015</option>
<option>2016</option>
<option>2017</option>
<option>2018</option>
<option>2019</option>
<option>2020</option>
</select><span data-valmsg-for="Business.AllocationOfPremiums.AllocationOfPremiumsContributions[{count}].Year" class="text-danger text-wrap" data-valmsg-replace="true"></span>
</div>
<div class="col-6 col-sm-5">
<input style="display:inline; width:80%;" autocomplete="off" type="text" name="Business.AllocationOfPremiums.AllocationOfPremiumsContributions[{count}].ContributionPercent"
class="allocation-contribution-percent percent form-control" aria-labelledby="business-allocation-contribution-header" data-val="true" data-val-number="The field ContributionPercent must be a number.">
<div style="display:inline;">%</div>
<span data-valmsg-for="Business.AllocationOfPremiums.AllocationOfPremiumsContributions[{count}].ContributionPercent" class="text-danger text-wrap" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-4 text-left text-sm-right">
<button type="button" data-service-count="{count}" class="btn btn-link remove-allocations-of-premiums-year">
<i class="fa fa-trash"></i> Delete Entry </button>
</div>
</div>
</div>
</div>
<div class="add-documents-template hidden">
<div id="business-allocation-of-premiums-file-inputs-{count}" class="allocation-of-premiums-file-inputs-hidden">
<div class="row mb-2">
<div class="col-sm-8">
<input type="file" accept=".jpg, .png, .jpeg, .pdf, .tif, .tiff" style="overflow: hidden;" class="form-control allocation-of-premiums-input-file" id="business-allocation-of-premiums-doc_{count}"
name="business.AllocationOfPremiumsDoc_{count}" @*="" data-val="true" data-val-shkfilesize="Invalid file size" *@="" aria-labelledby="business-flow-alternative-allocation-supporting-docs-header">
<span data-valmsg-for="business.AllocationOfPremiumsDoc_{count}" class="text-danger" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-4">
<button type="button" data-service-count="{count}" class="btn btn-link remove-allocations-of-premiums-input-file">
<i class="fa fa-trash"></i> DELETE FILE </button>
</div>
</div>
</div>
</div>
</section>
<!-- SECTION 14. -->
<section id="option1section14" class="datalosswarning-on">
<div class="question-group">
<div class="row title-icon">
<div class="col-sm-12">
<h2>
<i class="fal fa-money-check-alt"></i> Payment Election
</h2>
</div>
</div>
<div class="row title-desc">
<div class="col-sm-12">
<p> Please let us know how you would like to receive your settlement payment if your claim is deemed valid.</p>
<p> Final determinations of claim amounts will not be made until after processing by the Claims Administrator is complete. Claims will not be paid if the value is equal to or less than $5.00.</p>
<p> Claimants who submit valid, approved claims shall receive a pro-rata percentage of the Net Settlement Fund allocated to their type of coverage (fully-insured or self-funded) based upon their estimated proportion of the cumulative
total of premiums and/or administrative fees paid by all claimants.</p>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="payment-election-wrapper">
<div class="row mb-2">
<div class="col-sm-6">
<label class="required-field-label" for="Business_Shared_SelectedPaymentOption">Payment Option</label>
<select class="form-control" data-val="true" data-val-required="This is required." id="Business_Shared_SelectedPaymentOption" name="Business.Shared.SelectedPaymentOption">
<option value="" selected="">Please Select</option>
<option value="Venmo">Venmo</option>
<option value="PayPal">PayPal</option>
<option value="Pre-paid Card">Pre-paid Card</option>
<option value="Check">Check</option>
</select><span class="text-danger field-validation-valid" data-valmsg-for="Business.Shared.SelectedPaymentOption" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-6 payment-option-user" style="display:none">
<label for="Business_Shared_PaymentOptionUsername">Venmo Username</label>
<input autocomplete="off" type="text" class="form-control" aria-labelledby="Business_Shared_PaymentOptionUsername" data-val="true" data-val-requiredif="This is required." data-val-requiredif-comp="isequalto"
data-val-requiredif-other="SelectedPaymentOption" data-val-requiredif-value="Venmo" id="Business_Shared_PaymentOptionUsername" name="Business.Shared.PaymentOptionUsername" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Business.Shared.PaymentOptionUsername" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-6 payment-option-email" style="display:none">
<label for="Business_Shared_PayPalEmail">PayPal Email</label>
<input autocomplete="off" type="text" class="form-control" aria-labelledby="Business_Shared_PayPalEmail" data-val="true" data-val-email="Invalid Email Format." data-val-regex="Invalid Email Format."
data-val-regex-pattern="^[\w!#$%&'*+\-/=?\^_`{|}~]+(\.[\w!#$%&'*+\-/=?\^_`{|}~]+)*@((([\-\w]+\.)+[a-zA-Z0-9\-]{2,})|(([0-9]{1,3}\.){3}[0-9]{1,3}))$" data-val-requiredif="This is required."
data-val-requiredif-comp="isequalto" data-val-requiredif-other="SelectedPaymentOption" data-val-requiredif-value="PayPal" id="Business_Shared_PayPalEmail" name="Business.Shared.PayPalEmail" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Business.Shared.PayPalEmail" data-valmsg-replace="true"></span>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<!-- SECTION 15. -->
<section id="option1section15" class="datalosswarning-on review-section">
<div class="summary-section confirmation-section" id="contact-text" style="display: none">
<div class="row title-icon">
<div class="col-sm-12">
<h2>
<i class="fal fa-check-circle"></i> Confirmation
</h2>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<p>Your claim form has been submitted successfully. Please keep the Claim Number below for your records.</p>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="alert alert-secondary">
<strong>Claim Number:</strong>
<span class="confirmation-claim-number"></span>
</div>
</div>
</div>
<div class="ConfirmationPageUploadedDocuments" style="display: none;">
<div class="row">
<div class="col-md-12">
<h4>Supporting Documentation</h4>
</div>
</div>
</div>
</div>
<button type="button" style="display:none;" class="btn btn-lg btn-primary float-right print-claim">
<span>Print a Copy of Your Claim</span> <i class="fad fa-print"></i>
</button>
<!-- Header -->
<div class="summary-section please-review">
<div class="row title-icon">
<div class="col-sm-12">
<h2>
<i class="fal fa-file-contract"></i> Review
</h2>
</div>
</div>
<div class="row title-desc mb-0">
<div class="col-sm-12"> Please review your claim information below. If you need to make any edits to your claim, you may go back to a page by clicking that section of the progress bar or clicking the Back button at the bottom of the
page. If everything is correct, complete the <a href="#business-review-signature-header">Signature</a> section at the bottom of the page and click the Submit button. </div>
</div>
</div>
<!-- Business Info -->
<div class="summary-section">
<div class="row title-icon">
<div class="col-sm-12">
<h2 id="business-review-businessinfo-header" class="review-businessinfo-header">
<i class="fal fa-building"></i> Business Information
</h2>
</div>
</div>
<div class="row sub-title">
<div class="col-sm-12">
<h5>Full Name of Company</h5>
<hr>
</div>
</div>
<div class="row mb-2">
<div class="col-sm-12">
<label class="control-label" for="Business_BusinessContactInfo_CompanyName_Summary">Company</label>
<p class="form-control-static" id="Business_BusinessContactInfo_CompanyName_Summary"></p>
</div>
</div>
<div class="row sub-title">
<div class="col-sm-12">
<h5>Primary Headquarters Mailing Address</h5>
<hr>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="control-label" for="Business_Shared_MailingStreetLine1_Summary">Street Line 1</label>
<p class="form-control-static" id="Business_Shared_MailingStreetLine1_Summary"></p>
</div>
<div class="col-sm-6">
<label class="control-label" for="Business_Shared_MailingStreetLine2_Summary">Street Line 2</label>
<p class="form-control-static" id="Business_Shared_MailingStreetLine2_Summary"></p>
</div>
</div>
<div class="row mb-2">
<div class="col-sm-6">
<label class="control-label" for="Business_Shared_MailingCity_Summary">City</label>
<p class="form-control-static" id="Business_Shared_MailingCity_Summary"></p>
</div>
<div class="col-sm-3 review-field-us">
<label class="control-label" for="Business_Shared_MailingSubDivision_Summary">State</label>
<p class="form-control-static" id="Business_Shared_MailingSubDivision_Summary"></p>
</div>
<div class="col-sm-3 review-field-us">
<label class="control-label" for="Business_Shared_MailingPostalCode_Summary">Zip</label>
<p class="form-control-static" id="Business_Shared_MailingPostalCode_Summary"></p>
</div>
<div class="col-sm-3 review-field-non-us">
<label class="control-label" for="Business_Shared_MailingSubDivisionNonUS_Summary">Province</label>
<p class="form-control-static" id="Business_Shared_MailingSubDivisionNonUS_Summary"></p>
</div>
<div class="col-sm-3 review-field-non-us">
<label class="control-label" for="Business_Shared_MailingPostalCodeNonUS_Summary">Postal Code</label>
<p class="form-control-static" id="Business_Shared_MailingPostalCodeNonUS_Summary"></p>
</div>
<div class="col-sm-3 review-field-non-us">
<label class="control-label" for="Business_Shared_MailingCountry_Summary">Country</label>
<p class="form-control-static" id="Business_Shared_MailingCountry_Summary"></p>
</div>
</div>
<div class="row sub-title">
<div class="col-sm-12">
<h5>Current Company Contact (Name and Title)</h5>
<hr>
</div>
</div>
<div class="row">
<div class="col-sm-3">
<label class="control-label" for="Business_Shared_FirstName_Summary">First Name</label>
<p class="form-control-static" id="Business_Shared_FirstName_Summary"></p>
</div>
<div class="col-sm-3">
<label class="control-label" for="Business_Shared_MiddleInitial_Summary">Middle Initial</label>
<p class="form-control-static" id="Business_Shared_MiddleInitial_Summary"></p>
</div>
<div class="col-sm-6">
<label class="control-label" for="Business_Shared_LastName_Summary">Last Name</label>
<p class="form-control-static" id="Business_Shared_LastName_Summary"></p>
</div>
</div>
<div class="row mb-2">
<div class="col-sm-12">
<label class="control-label" for="Business_BusinessContactInfo_Title_Summary">Title</label>
<p class="form-control-static" id="Business_BusinessContactInfo_Title_Summary"></p>
</div>
</div>
<div class="row sub-title">
<div class="col-sm-12">
<h5>Office Phone Number</h5>
<hr>
</div>
</div>
<div class="row mb-2">
<div class="col-sm-12 review-field-us">
<label class="control-label" for="Business_Shared_PhoneNumber_Summary">Phone</label>
<p class="form-control-static" id="Business_Shared_PhoneNumber_Summary"></p>
</div>
<div class="col-sm-12 review-field-non-us">
<label class="control-label" for="Business_Shared_PhoneNumberNonUS_Summary">Phone</label>
<p class="form-control-static" id="Business_Shared_PhoneNumberNonUS_Summary"></p>
</div>
</div>
<div class="row sub-title">
<div class="col-sm-12">
<h5>Company Contact Email Address</h5>
<hr>
</div>
</div>
<div class="row mb-2">
<div class="col-sm-12">
<label class="control-label" for="Business_Shared_EmailAddress_Summary">Email Address</label>
<p class="form-control-static" id="Business_Shared_EmailAddress_Summary"></p>
</div>
</div>
</div>
<!-- Health Plan -->
<div class="summary-section">
<div class="row title-icon">
<div class="col-sm-12">
<h2 id="business-review-healthplan-header" class="review-healthplan-header">
<i class="fal fa-stethoscope"></i> Health Plan Details
</h2>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="review-healthplans"></div>
</div>
</div>
</div>
<!-- Allocations of Premiums -->
<div class="summary-section">
<div class="row title-icon">
<div class="col-sm-12">
<h2 id="business-review-allocationofpremiums-header" class="review-allocationofpremiums-header">
<i class="fal fa-file-contract"></i> Allocation of Premiums
</h2>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div class="review-allocation-alternative-selected allocation-option" style="display:none;">
<div class="wrapper">
<h3>Alternative Contribution % Selected</h3>
<div class="icon"><i class="fal fa-file-alt"></i></div>
</div>
</div>
<div class="review-allocation-default-selected allocation-option" style="display:none;">
<div class="wrapper">
<h3>Default Option Selected</h3>
<div class="icon"><i class="fal fa-check-circle"></i></div>
</div>
</div>
</div>
</div>
<div id="business-review-alternative-option-section" class="review-alternative-option-section" style="display:none;">
<div class="row sub-title">
<div class="col-md-12">
<h5>Alternative Option</h5>
<hr>
</div>
</div>
<div class="review-contributions mb-3">
<div class="row">
<div class="col-6 col-sm-3 font-weight-bold">Plan Year</div>
<div class="col-6 col-sm-3 font-weight-bold">Contribution</div>
</div>
<hr>
<div class="review-alternative-options"></div>
</div>
<div class="row sub-title">
<div class="col-md-12">
<h5>Upload Supporting Documentation</h5>
<hr>
</div>
</div>
<div class="row">
<div class="col-md-12 review-supporting-document-summary"></div>
<div class="col-md-12 review-supporting-document-none-selected"></div>
</div>
</div>
<div style="display: none" class="upload-in-progress mt-4">
<div class="row">
<div class="col-md-12 text-center upload-in-progress-title"> Please Wait For Upload </div>
</div>
<div class="row">
<div class="col-md-12 review-supporting-document-list">
</div>
</div>
<div class="failed-upload-block" style="display: none">
<div class="row">
<div class="col-md-12">
<b>Upload Failed For Files</b>
</div>
</div>
<div class="row">
<div class="col-md-12 failed-file-list" style="color:red;"></div>
</div>
</div>
</div>
</div>
<!-- Payment Election -->
<div class="summary-section">
<div class="row title-icon">
<div class="col-sm-12">
<h2 id="business-review-paymentelection-header" class="review-paymentelection-header">
<i class="fal fa-money-check-alt"></i> Payment Election
</h2>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="control-label" for="Business_Shared_SelectedPaymentOption">Payment Option</label>
<p class="form-control-static" id="Business_Shared_SelectedPaymentOption_Summary"></p>
</div>
<div class="col-sm-6 payment-option-user">
<label class="control-label" for="Business_Shared_PaymentOptionUsername">Venmo Username</label>
<p class="form-control-static" id="Business_Shared_PaymentOptionUsername_Summary"></p>
</div>
<div class="col-sm-6 payment-option-email">
<label class="control-label" for="Business_Shared_PayPalEmail">PayPal Email</label>
<p class="form-control-static" id="Business_Shared_PayPalEmail_Summary"></p>
</div>
</div>
</div>
<!-- Signature -->
<div class="summary-section">
<div class="row title-icon">
<div class="col-sm-12">
<h2 id="business-review-signature-header" class="review-signature-header">
<i class="fal fa-file-signature"></i> Signature
</h2>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="alert alert-secondary">
<div class="row">
<div class="col-sm-1" style="max-width: 20px;">
<input type="checkbox" data-val="true" data-val-required="This is required." id="Business_Shared_AffirmSignature" name="Business.Shared.AffirmSignature" value="true" aria-required="true">
</div>
<div class="col-sm-11">
<label class="control-label required-field-label" for="Business_Shared_AffirmSignature">By checking this box, I affirm under the laws of the United States and the laws of my State of residence that the information supplied in
this Claim Form by the undersigned is true and correct to the best of my recollection, and that this form was executed on the date set forth below.</label>
</div>
</div>
</div>
<span class="text-danger field-validation-valid" data-valmsg-for="Business.Shared.AffirmSignature" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-12">
<div class="alert alert-secondary">
<div class="row">
<div class="col-sm-1" style="max-width: 20px;">
<input type="checkbox" data-val="true" data-val-required="This is required." id="Business_Shared_AffirmMayProvideAdditionalInfo" name="Business.Shared.AffirmMayProvideAdditionalInfo" value="true" aria-required="true">
</div>
<div class="col-sm-11">
<label class="control-label required-field-label" for="Business_Shared_AffirmMayProvideAdditionalInfo">By checking this box, I understand that I may be asked to provide supplemental information to the Claims Administrator and/or
Settlement Administrator before my claim will be considered complete and valid.</label>
</div>
</div>
</div>
<span class="text-danger field-validation-valid" data-valmsg-for="Business.Shared.AffirmMayProvideAdditionalInfo" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-lg-8">
<label class="control-label required-field-label" for="Business_Shared_Signature">Type your name in the box below to electronically sign your claim</label>
<input autocomplete="off" type="text" class="form-control" maxlength="200" data-val="true" data-val-required="Please type your name above." id="Business_Shared_Signature" name="Business.Shared.Signature" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Business.Shared.Signature" data-valmsg-replace="true"></span>
</div>
<div class="col-lg-4">
<label class="control-label signature-date-label" for="Business_Shared_SignatureDate">Date</label>
<input autocomplete="off" class="form-control" readonly="" type="text" id="Business_Shared_SignatureDate" name="Business.Shared.SignatureDate" value="10/11/2021">
<span class="text-danger field-validation-valid" data-valmsg-for="Business.Shared.SignatureDate" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-lg-8">
<label class="control-label required-field-label" for="Business_BusinessSignatureModel_CompanyTitle">Company Title</label>
<input autocomplete="off" type="text" class="form-control" maxlength="200" data-val="true" data-val-required="This is required." id="Business_BusinessSignatureModel_CompanyTitle" name="Business.BusinessSignatureModel.CompanyTitle"
value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Business.BusinessSignatureModel.CompanyTitle" data-valmsg-replace="true"></span>
</div>
</div>
</div>
<div class="review-health-plan-template hidden">
<div class="row sub-title">
<div class="col-sm-12">
<h5 class="review-healthplan-title"></h5>
<hr>
</div>
</div>
<div class="row">
<div class="col-sm-3">
<label class="control-label">Health Plan Name</label>
<p class="form-control-static review-health-plan-name"></p>
</div>
<div class="col-sm-3">
<label class="control-label">Group #</label>
<p class="form-control-static review-health-plan-group-number"></p>
</div>
<div class="col-sm-3">
<label class="control-label">Coverage Start Date</label>
<p class="form-control-static review-health-plan-coverage-start-date"></p>
</div>
<div class="col-sm-3">
<label class="control-label">Coverage End Date</label>
<p class="form-control-static review-health-plan-coverage-end-date"></p>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="control-label">Was this plan purchased through a Purchasing Entity?</label>
</div>
<div class="col-sm-3">
<p class="form-control-static review-purchased-through-entity"></p>
</div>
</div>
<div class="review-purchased-through-entity-row">
<div class="row">
<div class="col-sm-1" style="max-width: 20px;">
<input type="checkbox" class="acquired-through-another-entity" disabled="">
</div>
<div class="col-sm-11">
<label class="font-weight-normal">Check this box if your company/business/entity acquired its health plan through another purchasing entity, such as a Professional Employer Organization ("PEO").</label>
</div>
</div>
<div class="row">
<div class="col-sm-1" style="max-width: 20px;">
</div>
<div class="col-sm-4">
<label class="control-label">Purchasing Entity</label>
</div>
<div class="col-sm-7">
<p class="form-control-static review-purchasing-entity"></p>
</div>
</div>
<div class="row">
<div class="col-sm-1" style="max-width: 20px;">
<input type="checkbox" class="service-on-behalf-of-others" disabled="">
</div>
<div class="col-sm-11">
<label class="font-weight-normal">Check this box if you are a PEO, Union, Trade Association, or other associational entity that collected payment for, contracted with or purchased a BCBS health insurance or administrative services
plan on behalf of your client companies, customers or members directly from a BCBS company.</label>
</div>
</div>
</div>
</div>
<div class="review-alternative-options-template hidden">
<div class="review-allocation-row-hidden">
<div class="row">
<div class="col-6 col-sm-3">
<p class="form-control-static review-alternative-option-year"></p>
</div>
<div class="col-6 col-sm-3">
<p class="form-control-static review-alternative-option-contribution" style="display:inline;"></p>
<p style="display:inline;">%</p>
</div>
</div>
</div>
</div>
<div class="claim-submit-error-text" style="display: none">
<div class="row response-section">
<div class="col-sm-12">
<div class="alert alert-danger">
<h4 class="mb-2">
<i class="fa fa-exclamation-triangle mr-2 claim-submit-error-icon-warning"></i>
<i class="fad fa-spinner-third fa-spin mr-2 claim-submit-error-icon-working" style="display: none;"></i> Error
</h4>
<div class="claim-submit-error-subheader">Your Claim Form Has Not Been Submitted</div>
<div class="claim-submit-error-text-message"></div>
</div>
</div>
</div>
</div>
</section>
</div>
<!-- #endregion -->
<!-- #region OPTION 2. -->
<!-- SECTION 21. -->
<div id="employee-flow">
<section id="option2section21" class="datalosswarning-on">
<div class="question-group">
<div class="form-horizontal">
<div class="row title-icon">
<div class="col-sm-12">
<h2>
<i class="fal fa-address-card"></i> Subscriber Information
</h2>
</div>
</div>
<div class="row">
<div class="col-md-4">
<label class="control-label required-field-label" for="Employee_Shared_FirstName">First Name</label>
<input autocomplete="off" type="text" class="form-control" maxlength="100" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" data-val-required="This is required."
id="Employee_Shared_FirstName" name="Employee.Shared.FirstName" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.Shared.FirstName" data-valmsg-replace="true"></span>
</div>
<div class="col-md-2">
<label class="control-label text-truncate" for="Employee_Shared_MiddleInitial">Middle Initial</label>
<input autocomplete="off" type="text" class="form-control" maxlength="1" data-val="true" data-val-maxlength="This field can only contain one character." data-val-maxlength-max="1" id="Employee_Shared_MiddleInitial"
name="Employee.Shared.MiddleInitial" value="">
</div>
<div class="col-md-6">
<label class="control-label required-field-label" for="Employee_Shared_LastName">Last Name</label>
<input autocomplete="off" type="text" class="form-control" maxlength="100" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" data-val-required="This is required."
id="Employee_Shared_LastName" name="Employee.Shared.LastName" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.Shared.LastName" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-md-6">
<label class="control-label required-field-label" for="Employee_Shared_MailingStreetLine1">Street Line 1</label>
<input autocomplete="off" type="text" class="form-control" maxlength="200" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" data-val-required="This is required."
id="Employee_Shared_MailingStreetLine1" name="Employee.Shared.MailingStreetLine1" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.Shared.MailingStreetLine1" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6">
<label class="control-label" for="Employee_Shared_MailingStreetLine2">Street Line 2</label>
<input autocomplete="off" type="text" class="form-control" maxlength="200" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" id="Employee_Shared_MailingStreetLine2"
name="Employee.Shared.MailingStreetLine2" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.Shared.MailingStreetLine2" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-md-6 col-lg-6">
<label class="control-label required-field-label" for="Employee_Shared_MailingCity">City</label>
<input autocomplete="off" type="text" class="form-control" maxlength="200" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" data-val-required="This is required."
id="Employee_Shared_MailingCity" name="Employee.Shared.MailingCity" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.Shared.MailingCity" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6 col-lg-6 div-country-us">
<label class="control-label required-field-label" for="Employee_Shared_MailingSubDivision">State</label>
<select class="form-control" data-val="true" data-val-requiredif="State or Province is required." data-val-requiredif-comp="isequalto" data-val-requiredif-other="MailingCountry" data-val-requiredif-value="US"
id="Employee_Shared_MailingSubDivision" name="Employee.Shared.MailingSubDivision">
<option value="" selected="selected"></option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AS">American Samoa</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="GU">Guam</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MP">Northern Mariana Islands</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="PR">Puerto Rico</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="VI">U.S. Virgin Islands</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
<option value="AA">AA</option>
<option value="AP">AP</option>
<option value="AE ">AE </option>
</select>
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.Shared.MailingSubDivision" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6 col-lg-6 div-country-non-us" style="display:none">
<label class="control-label required-field-label" for="Employee_Shared_MailingSubDivisionNonUS">Province</label>
<input autocomplete="off" type="text" class="form-control province" maxlength="200" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200"
data-val-requiredif="State or Province is required." data-val-requiredif-comp="isnotequalto" data-val-requiredif-other="MailingCountry" data-val-requiredif-value="US" id="Employee_Shared_MailingSubDivisionNonUS"
name="Employee.Shared.MailingSubDivisionNonUS" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.Shared.MailingSubDivisionNonUS" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-md-6 col-lg-6 div-country-us">
<label class="control-label required-field-label" for="Employee_Shared_MailingPostalCode">Zip</label>
<input autocomplete="off" type="text" class="zip form-control" maxlength="10" data-val="true" data-val-maxlength="This field can contain a maximum of 10 characters." data-val-maxlength-max="10"
data-val-regex="Please enter a five- or nine-digit ZIP code." data-val-regex-pattern="^\d{5}(?:[-\s]?\d{4})?$" data-val-requiredif="ZIP Code is required." data-val-requiredif-comp="isequalto"
data-val-requiredif-other="MailingCountry" data-val-requiredif-value="US" id="Employee_Shared_MailingPostalCode" name="Employee.Shared.MailingPostalCode" value="">
<span class="text-danger zip field-validation-valid" data-valmsg-for="Employee.Shared.MailingPostalCode" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6 col-lg-6 div-country-non-us" style="display:none">
<label class="control-label required-field-label text-truncate" for="Employee_Shared_MailingPostalCodeNonUS">Postal Code</label>
<input autocomplete="off" type="text" class="form-control" maxlength="10" data-val="true" data-val-maxlength="This field can contain a maximum of 10 characters." data-val-maxlength-max="10"
data-val-requiredif="Postal Code is required." data-val-requiredif-comp="isnotequalto" data-val-requiredif-other="MailingCountry" data-val-requiredif-value="US" id="Employee_Shared_MailingPostalCodeNonUS"
name="Employee.Shared.MailingPostalCodeNonUS" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.Shared.MailingPostalCodeNonUS" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6 col-lg-6">
<label class="control-label required-field-label" for="Employee_Shared_MailingCountry">Country</label>
<select class="form-control" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" data-val-required="Country is required." id="Employee_Shared_MailingCountry"
name="Employee.Shared.MailingCountry">
<option value="" selected="selected"></option>
<option value="AD">Andorra</option>
<option value="AF">Afghanistan</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AL">Albania</option>
<option value="AM">Armenia</option>
<option value="AO">Angola</option>
<option value="AR">Argentina</option>
<option value="AT">Austria</option>
<option value="AU">Australia</option>
<option value="AZ">Azerbaijan</option>
<option value="BA">Bosnia and Herzegovina</option>
<option value="BB">Barbados</option>
<option value="BD">Bangladesh</option>
<option value="BE">Belgium</option>
<option value="BF">Burkina Faso</option>
<option value="BG">Bulgaria</option>
<option value="BH">Bahrain</option>
<option value="BI">Burundi</option>
<option value="BJ">Benin</option>
<option value="BN">Brunei Darussalam</option>
<option value="BO">Bolivia(Plurinational State of)</option>
<option value="BR">Brazil</option>
<option value="BS">Bahamas</option>
<option value="BT">Bhutan</option>
<option value="BW">Botswana</option>
<option value="BY">Belarus</option>
<option value="BZ">Belize</option>
<option value="CA">Canada</option>
<option value="CF">Central African Republic</option>
<option value="CG">Congo</option>
<option value="CI">Côte d'Ivoire</option>
<option value="CV">Cape Verde</option>
<option value="CL">Chile</option>
<option value="CM">Cameroon</option>
<option value="CN">China</option>
<option value="CO">Colombia</option>
<option value="CR">Costa Rica</option>
<option value="CU">Cuba</option>
<option value="KM">Comoros</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="DE">Germany</option>
<option value="DJ">Djibouti</option>
<option value="CD">Democratic Republic of the Congo</option>
<option value="DK">Denmark</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="DZ">Algeria</option>
<option value="EC">Ecuador</option>
<option value="EE">Estonia</option>
<option value="EG">Egypt</option>
<option value="ER">Eritrea</option>
<option value="ES">Spain</option>
<option value="ET">Ethiopia</option>
<option value="FI">Finland</option>
<option value="FJ">Fiji</option>
<option value="FM">Micronesia(Federated States of)</option>
<option value="FR">France</option>
<option value="GA">Gabon</option>
<option value="GD">Grenada</option>
<option value="GE">Georgia</option>
<option value="GH">Ghana</option>
<option value="GM">Gambia</option>
<option value="GN">Guinea</option>
<option value="GQ">Equatorial Guinea</option>
<option value="GR">Greece</option>
<option value="GT">Guatemala</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HN">Honduras</option>
<option value="HR">Croatia</option>
<option value="HT">Haiti</option>
<option value="HU">Hungary</option>
<option value="ID">Indonesia</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IN">India</option>
<option value="IQ">Iraq</option>
<option value="IR">Iran(Islamic Republic of)</option>
<option value="IS">Iceland</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JO">Jordan</option>
<option value="JP">Japan</option>
<option value="KE">Kenya</option>
<option value="KG">Kyrgyzstan</option>
<option value="KH">Cambodia</option>
<option value="KI">Kiribati</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="KP">Democratic People's Republic of Korea</option>
<option value="KR">Republic of Korea</option>
<option value="KW">Kuwait</option>
<option value="KZ">Kazakhstan</option>
<option value="LA">Lao People's Democratic Republic</option>
<option value="LB">Lebanon</option>
<option value="LC">Saint Lucia</option>
<option value="LI">Liechtenstein</option>
<option value="LK">Sri Lanka</option>
<option value="LR">Liberia</option>
<option value="LS">Lesotho</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="LV">Latvia</option>
<option value="LY">Libyan Arab Jamahiriya</option>
<option value="MA">Morocco</option>
<option value="MC">Monaco</option>
<option value="MD">Republic of Moldova</option>
<option value="ME">Montenegro</option>
<option value="MG">Madagascar</option>
<option value="MH">Marshall Islands</option>
<option value="MK">The former Yugoslav Republic of Macedonia</option>
<option value="ML">Mali</option>
<option value="MM">Myanmar</option>
<option value="MN">Mongolia</option>
<option value="MR">Mauritania</option>
<option value="MT">Malta</option>
<option value="MU">Mauritius</option>
<option value="MV">Maldives</option>
<option value="MW">Malawi</option>
<option value="MX">Mexico</option>
<option value="MY">Malaysia</option>
<option value="MZ">Mozambique</option>
<option value="NA">Namibia</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NI">Nicaragua</option>
<option value="NL">Netherlands</option>
<option value="NO">Norway</option>
<option value="NP">Nepal</option>
<option value="NR">Nauru</option>
<option value="NZ">New Zealand</option>
<option value="OM">Oman</option>
<option value="PA">Panama</option>
<option value="PE">Peru</option>
<option value="PG">Papua New Guinea</option>
<option value="PH">Philippines</option>
<option value="PK">Pakistan</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PW">Palau</option>
<option value="PY">Paraguay</option>
<option value="QA">Qatar</option>
<option value="RO">Romania</option>
<option value="RS">Serbia</option>
<option value="RU">Russian Federation</option>
<option value="RW">Rwanda</option>
<option value="SA">Saudi Arabia</option>
<option value="SB">Solomon Islands</option>
<option value="SC">Seychelles</option>
<option value="SD">Sudan</option>
<option value="SE">Sweden</option>
<option value="SG">Singapore</option>
<option value="SI">Slovenia</option>
<option value="SK">Slovakia</option>
<option value="SL">Sierra Leone</option>
<option value="SM">San Marino</option>
<option value="SN">Senegal</option>
<option value="SO">Somalia</option>
<option value="SR">Suriname</option>
<option value="ZA">South Africa</option>
<option value="SS">South Sudan</option>
<option value="ST">Sao Tome and Principe</option>
<option value="SV">El Salvador</option>
<option value="SY">Syrian Arab Republic</option>
<option value="SZ">Eswatini</option>
<option value="CH">Switzerland</option>
<option value="TD">Chad</option>
<option value="TG">Togo</option>
<option value="TH">Thailand</option>
<option value="TJ">Tajikistan</option>
<option value="TL">Timor - Leste</option>
<option value="TM">Turkmenistan</option>
<option value="TN">Tunisia</option>
<option value="TO">Tonga</option>
<option value="TR">Turkey</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TV">Tuvalu</option>
<option value="TW">Taiwan</option>
<option value="UA">Ukraine</option>
<option value="UG">Uganda</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom of Great Britain and Northern Ireland</option>
<option value="TZ">United Republic of Tanzania</option>
<option selected="selected" value="US">United States of America</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="VE">Venezuela(Bolivarian Republic of)</option>
<option value="VN">Viet Nam</option>
<option value="VU">Vanuatu</option>
<option value="WS">Samoa</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select>
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.Shared.MailingCountry" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-sm-6 div-country-us">
<label class="control-label required-field-label" for="Employee_Shared_PhoneNumber">Phone</label>
<input autocomplete="off" type="text" maxlength="14" class="form-control phone" data-val="true" data-val-maxlength="Phone number is too long. " data-val-maxlength-max="15" data-val-regex="Invalid phone number format."
data-val-regex-pattern="^(?:\+?1[-. ]?)?\(?([0-9]{3})\)?[-. ]?([0-9]{3})[-. ]?([0-9]{4})[ ]?(x\d{1,5})?$" data-val-requiredif="This is required." data-val-requiredif-comp="isequalto" data-val-requiredif-other="MailingCountry"
data-val-requiredif-value="US" id="Employee_Shared_PhoneNumber" name="Employee.Shared.PhoneNumber" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.Shared.PhoneNumber" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-6 div-country-non-us" style="display:none">
<label class="control-label required-field-label" for="Employee_Shared_PhoneNumberNonUS">Phone</label>
<input autocomplete="off" type="text" maxlength="14" class="form-control phone" data-val="true" data-val-maxlength="LocKey_PhoneNumberMustBeLimitedTo20Characters" data-val-maxlength-max="20" data-val-requiredif="This is required."
data-val-requiredif-comp="isnotequalto" data-val-requiredif-other="MailingCountry" data-val-requiredif-value="US" id="Employee_Shared_PhoneNumberNonUS" name="Employee.Shared.PhoneNumberNonUS" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.Shared.PhoneNumberNonUS" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-6">
<label class="control-label required-field-label" for="Employee_Shared_EmailAddress">Email</label>
<input autocomplete="off" type="text" class="form-control" maxlength="100" data-val="true" data-val-maxlength="Email entered is too long." data-val-maxlength-max="200" data-val-regex="Invalid Email Format."
data-val-regex-pattern="^[\w!#$%&'*+\-/=?\^_`{|}~]+(\.[\w!#$%&'*+\-/=?\^_`{|}~]+)*@((([\-\w]+\.)+[a-zA-Z0-9\-]{2,})|(([0-9]{1,3}\.){3}[0-9]{1,3}))$" data-val-required="This is required." id="Employee_Shared_EmailAddress"
name="Employee.Shared.EmailAddress" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.Shared.EmailAddress" data-valmsg-replace="true"></span>
</div>
</div>
</div>
</div>
</section>
<!-- SECTION 22. -->
<section id="option2section22" class="datalosswarning-on health-plan-details-section">
<div class="question-group">
<div class="form-horizontal">
<div class="row title-icon">
<div class="col-sm-12">
<h2>
<i class="fal fa-stethoscope"></i> Health Plan Details
</h2>
</div>
</div>
<div class="row title-desc">
<div class="col-sm-12"> Please do your best to provide as much information as you can below. While more information will assist the Claims Administrator in processing your claim, only boxes marked with an * are required. </div>
</div>
<div id="health-plan-wrapper-0" class="health-plan-wrapper">
<input autocomplete="off" type="hidden" id="Employee.HealthPlanDetails.Index" name="Employee.HealthPlanDetails.Index" value="0">
<div class="row sub-title">
<div class="col-sm-12">
<div class="row">
<div class="col-sm-8">
<div class="sub-num">1</div>
<h5 class="health-plan-heading">Health Plan Entry</h5>
</div>
<div class="col-sm-4">
<button type="button" data-service-count="0" class="remove-healthplan-btn btn btn-link float-right" style="display: none"><i class="fa fa-trash"></i> Delete Entry</button>
</div>
</div>
<hr>
</div>
</div>
<div class="row">
<div class="col-md-6 health-plan-name-form-group">
<label for="employee-health-plan-name-select-0" class="control-label">Health Plan Name</label>
<select id="employee-health-plan-name-select-0" class="health-plan-name-select" style="display: none;">
<option value=""></option>
<option value="Anthem Blue Cross Life and Health Insurance Company">Anthem Blue Cross Life and Health Insurance Company</option>
<option value="Anthem Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Kentucky)">Anthem Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Kentucky)</option>
<option value="Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Maine)">Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Maine)</option>
<option value="Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue Cross and Blue Shield (of New Hampshire)">Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue Cross and Blue Shield (of New Hampshire)</option>
<option value="Anthem Health Plans of Virginia, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Virginia)">Anthem Health Plans of Virginia, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Virginia)</option>
<option value="Anthem Health Plans, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Connecticut)">Anthem Health Plans, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Connecticut)</option>
<option value="Anthem Insurance Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana)">Anthem Insurance Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana)</option>
<option value="Arkansas Blue Cross and Blue Shield">Arkansas Blue Cross and Blue Shield</option>
<option value="Blue Benefits Administrators">Blue Benefits Administrators</option>
<option value="Blue Care Network of Michigan">Blue Care Network of Michigan</option>
<option value="Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company">Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company</option>
<option value="Blue Cross & Blue Shield of Rhode Island">Blue Cross & Blue Shield of Rhode Island</option>
<option value="Blue Cross and Blue Shield of Alabama">Blue Cross and Blue Shield of Alabama</option>
<option value="Blue Cross and Blue Shield of Georgia, Inc.">Blue Cross and Blue Shield of Georgia, Inc.</option>
<option value="Blue Cross and Blue Shield of Illinois">Blue Cross and Blue Shield of Illinois</option>
<option value="Blue Cross and Blue Shield of Kansas">Blue Cross and Blue Shield of Kansas</option>
<option value="Blue Cross and Blue Shield of Kansas City">Blue Cross and Blue Shield of Kansas City</option>
<option value="Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.">Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.</option>
<option value="Blue Cross and Blue Shield of Massachusetts, Inc.">Blue Cross and Blue Shield of Massachusetts, Inc.</option>
<option value="Blue Cross and Blue Shield of Minnesota">Blue Cross and Blue Shield of Minnesota</option>
<option value="Blue Cross and Blue Shield of Montana">Blue Cross and Blue Shield of Montana</option>
<option value="Blue Cross and Blue Shield of New Mexico">Blue Cross and Blue Shield of New Mexico</option>
<option value="Blue Cross and Blue Shield of North Carolina">Blue Cross and Blue Shield of North Carolina</option>
<option value="Blue Cross and Blue Shield of Oklahoma">Blue Cross and Blue Shield of Oklahoma</option>
<option value="Blue Cross and Blue Shield of Texas">Blue Cross and Blue Shield of Texas</option>
<option value="Blue Cross and Blue Shield of Vermont">Blue Cross and Blue Shield of Vermont</option>
<option value="Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a Anthem Blue Cross and Blue Shield">Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Blue Cross Blue Shield of Delaware">Blue Cross Blue Shield of Delaware</option>
<option value="Blue Cross Blue Shield of Louisiana">Blue Cross Blue Shield of Louisiana</option>
<option value="Blue Cross Blue Shield of Massachusetts">Blue Cross Blue Shield of Massachusetts</option>
<option value="Blue Cross Blue Shield of Michigan">Blue Cross Blue Shield of Michigan</option>
<option value="Blue Cross Blue Shield of Nebraska">Blue Cross Blue Shield of Nebraska</option>
<option value="Blue Cross Blue Shield of North Dakota">Blue Cross Blue Shield of North Dakota</option>
<option value="Blue Cross Blue Shield of Northeastern Pennsylvania">Blue Cross Blue Shield of Northeastern Pennsylvania</option>
<option value="Blue Cross Blue Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield">Blue Cross Blue Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Blue Cross Blue Shield of Wyoming">Blue Cross Blue Shield of Wyoming</option>
<option value="Blue Cross of California d/b/a Anthem Blue Cross">Blue Cross of California d/b/a Anthem Blue Cross</option>
<option value="Blue Cross of Idaho">Blue Cross of Idaho</option>
<option value="Blue Plus">Blue Plus</option>
<option value="Blue Shield of California">Blue Shield of California</option>
<option value="Blue Shield of California Life & Health Insurance Company">Blue Shield of California Life & Health Insurance Company</option>
<option value="BlueAdvantage Administrators of Arkansas">BlueAdvantage Administrators of Arkansas</option>
<option value="BlueChoice HealthPlan of South Carolina">BlueChoice HealthPlan of South Carolina</option>
<option value="BlueCross BlueShield of Arizona">BlueCross BlueShield of Arizona</option>
<option value="BlueCross BlueShield of Florida, Inc.">BlueCross BlueShield of Florida, Inc.</option>
<option value="BlueCross BlueShield of South Carolina">BlueCross BlueShield of South Carolina</option>
<option value="BlueCross BlueShield of Tennessee">BlueCross BlueShield of Tennessee</option>
<option value="BlueCross BlueShield of Western New York">BlueCross BlueShield of Western New York</option>
<option value="BlueShield of Northeastern New York">BlueShield of Northeastern New York</option>
<option value="California Physicians’ Service dba Blue Shield of California">California Physicians’ Service dba Blue Shield of California</option>
<option value="Capital Advantage Assurance Company (CAAC)">Capital Advantage Assurance Company (CAAC)</option>
<option value="Capital Advantage Insurance Company (CAIC)">Capital Advantage Insurance Company (CAIC)</option>
<option value="Capital BlueCross">Capital BlueCross</option>
<option value="Capital Health Plan, Inc.">Capital Health Plan, Inc.</option>
<option value="CareFirst BlueChoice, Inc.">CareFirst BlueChoice, Inc.</option>
<option value="CareFirst BlueCross BlueShield DC/Montgomery County/Prince George’s County/Virginia">CareFirst BlueCross BlueShield DC/Montgomery County/Prince George’s County/Virginia</option>
<option value="CareFirst BlueCross BlueShield Maryland">CareFirst BlueCross BlueShield Maryland</option>
<option value="CareFirst of Maryland, Inc. (CFMI)">CareFirst of Maryland, Inc. (CFMI)</option>
<option value="CBA Blue (Vermont)">CBA Blue (Vermont)</option>
<option value="CFA LLC">CFA LLC</option>
<option value="Claim Management Services, Inc. d/b/a Anthem Blue Cross and Blue Shield">Claim Management Services, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Community Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Ohio)">Community Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Ohio)</option>
<option value="Compcare Health Services Insurance Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of Wisconsin)">Compcare Health Services Insurance Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of
Wisconsin)</option>
<option value="Empire HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield">Empire HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield</option>
<option value="Empire HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield">Empire HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield</option>
<option value="Excellus BlueCross BlueShield">Excellus BlueCross BlueShield</option>
<option value="First Priority Health">First Priority Health</option>
<option value="First Priority Life">First Priority Life</option>
<option value="Florida Blue">Florida Blue</option>
<option value="Florida Health Care Plan, Inc.">Florida Health Care Plan, Inc.</option>
<option value="Group Hospitalization and Medical Services, Inc. (GHMSI)">Group Hospitalization and Medical Services, Inc. (GHMSI)</option>
<option value="Hawaii Medical Service Association (HMSA)">Hawaii Medical Service Association (HMSA)</option>
<option value="Health Advantage">Health Advantage</option>
<option value="HealthKeepers, Inc.">HealthKeepers, Inc.</option>
<option value="Healthwise">Healthwise</option>
<option value="Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Missouri)">Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Missouri)</option>
<option value="Highmark Blue Cross Blue Shield">Highmark Blue Cross Blue Shield</option>
<option value="Highmark Blue Cross Blue Shield of Delaware">Highmark Blue Cross Blue Shield of Delaware</option>
<option value="Highmark Blue Cross Blue Shield of West Virginia">Highmark Blue Cross Blue Shield of West Virginia</option>
<option value="Highmark Blue Shield">Highmark Blue Shield</option>
<option value="HMO Colorado, Inc.">HMO Colorado, Inc.</option>
<option value="HMO Colorado, Inc. d/b/a HMO Nevada, Inc.">HMO Colorado, Inc. d/b/a HMO Nevada, Inc.</option>
<option value="HMO Louisiana, Inc.">HMO Louisiana, Inc.</option>
<option value="HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Missouri)">HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Missouri)</option>
<option value="HMO Partners, Inc.">HMO Partners, Inc.</option>
<option value="Horizon Blue Cross Blue Shield of New Jersey">Horizon Blue Cross Blue Shield of New Jersey</option>
<option value="Independence Administrators">Independence Administrators</option>
<option value="Independence Blue Cross">Independence Blue Cross</option>
<option value="Independence Hospital Indemnity Plan">Independence Hospital Indemnity Plan</option>
<option value="Keystone Health Plan Central, Inc. (KHPC)">Keystone Health Plan Central, Inc. (KHPC)</option>
<option value="Keystone Health Plan East">Keystone Health Plan East</option>
<option value="Keystone Health Plan West">Keystone Health Plan West</option>
<option value="Matthew Thornton Health Plan, Inc.">Matthew Thornton Health Plan, Inc.</option>
<option value="Mountain State Blue Cross Blue Shield">Mountain State Blue Cross Blue Shield</option>
<option value="Premera Blue Cross">Premera Blue Cross</option>
<option value="Premera Blue Cross Blue Shield">Premera Blue Cross Blue Shield</option>
<option value="Premera Blue Cross Blue Shield of Alaska">Premera Blue Cross Blue Shield of Alaska</option>
<option value="QCC Insurance Company">QCC Insurance Company</option>
<option value="Regence BlueCross BlueShield of Oregon">Regence BlueCross BlueShield of Oregon</option>
<option value="Regence BlueCross BlueShield of Utah">Regence BlueCross BlueShield of Utah</option>
<option value="Regence BlueShield">Regence BlueShield</option>
<option value="Regence BlueShield of Idaho">Regence BlueShield of Idaho</option>
<option value="Regence Group Administrators">Regence Group Administrators</option>
<option value="Regence Health Maintenance of Oregon">Regence Health Maintenance of Oregon</option>
<option value="Regence HMO Oregon">Regence HMO Oregon</option>
<option value="Regence Life and Health Insurance Company">Regence Life and Health Insurance Company</option>
<option value="Regence ValueCare">Regence ValueCare</option>
<option value="RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross and Blue Shield">RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Colorado)">Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Colorado)
</option>
<option value="Triple-S Management Corp.">Triple-S Management Corp.</option>
<option value="Triple-S Salud, Inc.">Triple-S Salud, Inc.</option>
<option value="USAble Mutual Insurance Company">USAble Mutual Insurance Company</option>
<option value="Wellmark BCBS of Iowa">Wellmark BCBS of Iowa</option>
<option value="Wellmark BCBS of South Dakota">Wellmark BCBS of South Dakota</option>
<option value="Wellmark Health Plan of Iowa">Wellmark Health Plan of Iowa</option>
<option value="Wellmark Synergy Health Plan">Wellmark Synergy Health Plan</option>
<option value="Wellmark Value Health Plan">Wellmark Value Health Plan</option>
<option value="Wisconsin Collaborative Insurance Company">Wisconsin Collaborative Insurance Company</option>
<option value="Other">Other</option>
</select><span class="k-picker-wrap k-state-default"><input title="" class="form-control k-input ui-autocomplete-input"
autocomplete="off"><a tabindex="-1" title="Show All Items" class="fa fa-chevron-down plan-dropdown-selector k-select"></a></span>
<div class="row health-plan-name-other" style="display: none;">
<div class="col-12">
<label for="employee-health-plan-name-other-0" class="control-label">Other Health Plan Name</label>
<input id="employee-health-plan-name-other-0" autocomplete="off" class="form-control" type="text" maxlength="200">
</div>
</div>
<span class="text-danger field-validation-valid" data-valmsg-replace="true" data-valmsg-for="Employee.HealthPlanDetails[0].Name"></span>
<input autocomplete="off" type="text" class="health-plan-name" maxlength="200" tabindex="-1" aria-labelledby="employee-health-plan-name-select-0" data-val="true" data-val-maxlength="Plan name must be less than 200 characters."
data-val-maxlength-max="200" id="Employee_HealthPlanDetails_0__Name" name="Employee.HealthPlanDetails[0].Name" value="">
</div>
<div class="col-md-6">
<label class="control-label" for="Employee_HealthPlanDetails_0__GroupNumber">Group #</label>
<input autocomplete="off" type="text" class="form-control employee-group-number" maxlength="100" id="Employee_HealthPlanDetails_0__GroupNumber" name="Employee.HealthPlanDetails[0].GroupNumber" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.HealthPlanDetails[0].GroupNumber" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-md-12">
<label class="control-label required-field-label" for="Employee_HealthPlanDetails_0__EmployerName">Employer Name</label>
<input autocomplete="off" type="text" class="form-control employer-name" maxlength="100" data-val="true" data-val-required="This is required." id="Employee_HealthPlanDetails_0__EmployerName"
name="Employee.HealthPlanDetails[0].EmployerName" value="" aria-required="true">
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.HealthPlanDetails[0].EmployerName" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-md-12">
<label class="control-label" for="Employee_HealthPlanDetails_0__EmployerMailingAddress">Employer Address</label>
<input autocomplete="off" type="text" class="form-control employer-address" maxlength="100" id="Employee_HealthPlanDetails_0__EmployerMailingAddress" name="Employee.HealthPlanDetails[0].EmployerMailingAddress" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.HealthPlanDetails[0].EmployerMailingAddress" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-lg-12 col-xl-4">
<label class="control-label" for="Employee_HealthPlanDetails_0__SubscriberID">Subscriber or Member ID</label>
<input autocomplete="off" type="text" class="form-control subscriber-id" value="" maxlength="100" id="Employee_HealthPlanDetails_0__SubscriberID" name="Employee.HealthPlanDetails[0].SubscriberID">
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.HealthPlanDetails[0].SubscriberID" data-valmsg-replace="true"></span>
</div>
<div class="col-lg-6 col-xl-4">
<label class="control-label start-date-label" for="Employee_HealthPlanDetails_0__CoverageStartDate">Coverage Start Date</label>
<span class="k-widget k-datepicker form-control coverageStartDate" style=""><span class="k-picker-wrap k-state-default"><input autocomplete="off" type="text" class="form-control coverageStartDate k-input" value=""
placeholder="MM/YYYY" id="Employee_HealthPlanDetails_0__CoverageStartDate" name="Employee.HealthPlanDetails[0].CoverageStartDate" data-role="datepicker" role="combobox" aria-expanded="false"
aria-owns="Employee_HealthPlanDetails_0__CoverageStartDate_dateview" aria-disabled="false" style="width: 100%;"><span class="k-icon k-i-warning"></span><span unselectable="on" class="k-select" aria-label="select"
role="button" aria-controls="Employee_HealthPlanDetails_0__CoverageStartDate_dateview"><span class="k-icon k-i-calendar"></span></span></span></span>
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.HealthPlanDetails[0].CoverageStartDate" data-valmsg-replace="true"></span>
</div>
<div class="col-lg-6 col-xl-4">
<label class="control-label" for="Employee_HealthPlanDetails_0__CoverageEndDate">Coverage End Date</label>
<span class="k-widget k-datepicker form-control coverageEndDate" style=""><span class="k-picker-wrap k-state-default"><input autocomplete="off" type="text" class="form-control coverageEndDate k-input" value=""
placeholder="MM/YYYY" id="Employee_HealthPlanDetails_0__CoverageEndDate" name="Employee.HealthPlanDetails[0].CoverageEndDate" data-role="datepicker" role="combobox" aria-expanded="false"
aria-owns="Employee_HealthPlanDetails_0__CoverageEndDate_dateview" aria-disabled="false" style="width: 100%;"><span class="k-icon k-i-warning"></span><span unselectable="on" class="k-select" aria-label="select" role="button"
aria-controls="Employee_HealthPlanDetails_0__CoverageEndDate_dateview"><span class="k-icon k-i-calendar"></span></span></span></span>
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.HealthPlanDetails[0].CoverageEndDate" data-valmsg-replace="true"></span>
</div>
</div>
</div>
<hr>
<div class="alert alert-danger" role="alert" id="groupNrRequiredErrMsg" style="display: none">
<i class="fa fa-exclamation-circle"></i> Group # field is required.
</div>
<div class="alert alert-danger" role="alert" id="coverageStartDateRequiredErrMsg" style="display: none">
<i class="fa fa-exclamation-circle"></i> LocKey_CoverageStartDateRequiredErrMsgRequiredErrMsg
</div>
<div class="alert alert-danger" role="alert" id="coverageEndDateRequiredErrMsg" style="display: none">
<i class="fa fa-exclamation-circle"></i> LocKey_CoverageEndDateRequiredErrMsgRequiredErrMsg
</div>
<button type="button" class="btn add-healthplan-btn btn-primary-outline"><i class="fa fa-plus-square"></i> Add another Health Plan</button>
</div>
</div>
<div class="add-healthplan-template hidden">
<div id="health-plan-wrapper-{count}" class="health-plan-wrapper-hidden">
<div class="row sub-title">
<div class="col-sm-12">
<div class="row">
<div class="col-sm-8">
<div class="sub-num"></div>
<h5 class="health-plan-heading">Health Plan Entry</h5>
</div>
<div class="col-sm-4">
<button type="button" data-service-count="{count}" class="remove-healthplan-btn btn btn-link float-right"><i class="fa fa-trash"></i> Delete Entry</button>
</div>
</div>
<hr>
</div>
</div>
<div class="row">
<div class="col-md-6 health-plan-name-form-group">
<label for="employee-health-plan-name-select-{count}" class="control-label">Health Plan Name</label>
<select id="employee-health-plan-name-select-{count}" class="health-plan-name-select" style="display: none;">
<option value=""></option>
<option value="Anthem Blue Cross Life and Health Insurance Company">Anthem Blue Cross Life and Health Insurance Company</option>
<option value="Anthem Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Kentucky)">Anthem Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Kentucky)</option>
<option value="Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Maine)">Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Maine)</option>
<option value="Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue Cross and Blue Shield (of New Hampshire)">Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue Cross and Blue Shield (of New Hampshire)</option>
<option value="Anthem Health Plans of Virginia, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Virginia)">Anthem Health Plans of Virginia, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Virginia)</option>
<option value="Anthem Health Plans, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Connecticut)">Anthem Health Plans, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Connecticut)</option>
<option value="Anthem Insurance Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana)">Anthem Insurance Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana)</option>
<option value="Arkansas Blue Cross and Blue Shield">Arkansas Blue Cross and Blue Shield</option>
<option value="Blue Benefits Administrators">Blue Benefits Administrators</option>
<option value="Blue Care Network of Michigan">Blue Care Network of Michigan</option>
<option value="Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company">Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company</option>
<option value="Blue Cross & Blue Shield of Rhode Island">Blue Cross & Blue Shield of Rhode Island</option>
<option value="Blue Cross and Blue Shield of Alabama">Blue Cross and Blue Shield of Alabama</option>
<option value="Blue Cross and Blue Shield of Georgia, Inc.">Blue Cross and Blue Shield of Georgia, Inc.</option>
<option value="Blue Cross and Blue Shield of Illinois">Blue Cross and Blue Shield of Illinois</option>
<option value="Blue Cross and Blue Shield of Kansas">Blue Cross and Blue Shield of Kansas</option>
<option value="Blue Cross and Blue Shield of Kansas City">Blue Cross and Blue Shield of Kansas City</option>
<option value="Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.">Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.</option>
<option value="Blue Cross and Blue Shield of Massachusetts, Inc.">Blue Cross and Blue Shield of Massachusetts, Inc.</option>
<option value="Blue Cross and Blue Shield of Minnesota">Blue Cross and Blue Shield of Minnesota</option>
<option value="Blue Cross and Blue Shield of Montana">Blue Cross and Blue Shield of Montana</option>
<option value="Blue Cross and Blue Shield of New Mexico">Blue Cross and Blue Shield of New Mexico</option>
<option value="Blue Cross and Blue Shield of North Carolina">Blue Cross and Blue Shield of North Carolina</option>
<option value="Blue Cross and Blue Shield of Oklahoma">Blue Cross and Blue Shield of Oklahoma</option>
<option value="Blue Cross and Blue Shield of Texas">Blue Cross and Blue Shield of Texas</option>
<option value="Blue Cross and Blue Shield of Vermont">Blue Cross and Blue Shield of Vermont</option>
<option value="Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a Anthem Blue Cross and Blue Shield">Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Blue Cross Blue Shield of Delaware">Blue Cross Blue Shield of Delaware</option>
<option value="Blue Cross Blue Shield of Louisiana">Blue Cross Blue Shield of Louisiana</option>
<option value="Blue Cross Blue Shield of Massachusetts">Blue Cross Blue Shield of Massachusetts</option>
<option value="Blue Cross Blue Shield of Michigan">Blue Cross Blue Shield of Michigan</option>
<option value="Blue Cross Blue Shield of Nebraska">Blue Cross Blue Shield of Nebraska</option>
<option value="Blue Cross Blue Shield of North Dakota">Blue Cross Blue Shield of North Dakota</option>
<option value="Blue Cross Blue Shield of Northeastern Pennsylvania">Blue Cross Blue Shield of Northeastern Pennsylvania</option>
<option value="Blue Cross Blue Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield">Blue Cross Blue Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Blue Cross Blue Shield of Wyoming">Blue Cross Blue Shield of Wyoming</option>
<option value="Blue Cross of California d/b/a Anthem Blue Cross">Blue Cross of California d/b/a Anthem Blue Cross</option>
<option value="Blue Cross of Idaho">Blue Cross of Idaho</option>
<option value="Blue Plus">Blue Plus</option>
<option value="Blue Shield of California">Blue Shield of California</option>
<option value="Blue Shield of California Life & Health Insurance Company">Blue Shield of California Life & Health Insurance Company</option>
<option value="BlueAdvantage Administrators of Arkansas">BlueAdvantage Administrators of Arkansas</option>
<option value="BlueChoice HealthPlan of South Carolina">BlueChoice HealthPlan of South Carolina</option>
<option value="BlueCross BlueShield of Arizona">BlueCross BlueShield of Arizona</option>
<option value="BlueCross BlueShield of Florida, Inc.">BlueCross BlueShield of Florida, Inc.</option>
<option value="BlueCross BlueShield of South Carolina">BlueCross BlueShield of South Carolina</option>
<option value="BlueCross BlueShield of Tennessee">BlueCross BlueShield of Tennessee</option>
<option value="BlueCross BlueShield of Western New York">BlueCross BlueShield of Western New York</option>
<option value="BlueShield of Northeastern New York">BlueShield of Northeastern New York</option>
<option value="California Physicians’ Service dba Blue Shield of California">California Physicians’ Service dba Blue Shield of California</option>
<option value="Capital Advantage Assurance Company (CAAC)">Capital Advantage Assurance Company (CAAC)</option>
<option value="Capital Advantage Insurance Company (CAIC)">Capital Advantage Insurance Company (CAIC)</option>
<option value="Capital BlueCross">Capital BlueCross</option>
<option value="Capital Health Plan, Inc.">Capital Health Plan, Inc.</option>
<option value="CareFirst BlueChoice, Inc.">CareFirst BlueChoice, Inc.</option>
<option value="CareFirst BlueCross BlueShield DC/Montgomery County/Prince George’s County/Virginia">CareFirst BlueCross BlueShield DC/Montgomery County/Prince George’s County/Virginia</option>
<option value="CareFirst BlueCross BlueShield Maryland">CareFirst BlueCross BlueShield Maryland</option>
<option value="CareFirst of Maryland, Inc. (CFMI)">CareFirst of Maryland, Inc. (CFMI)</option>
<option value="CBA Blue (Vermont)">CBA Blue (Vermont)</option>
<option value="CFA LLC">CFA LLC</option>
<option value="Claim Management Services, Inc. d/b/a Anthem Blue Cross and Blue Shield">Claim Management Services, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Community Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Ohio)">Community Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Ohio)</option>
<option value="Compcare Health Services Insurance Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of Wisconsin)">Compcare Health Services Insurance Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of
Wisconsin)</option>
<option value="Empire HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield">Empire HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield</option>
<option value="Empire HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield">Empire HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield</option>
<option value="Excellus BlueCross BlueShield">Excellus BlueCross BlueShield</option>
<option value="First Priority Health">First Priority Health</option>
<option value="First Priority Life">First Priority Life</option>
<option value="Florida Blue">Florida Blue</option>
<option value="Florida Health Care Plan, Inc.">Florida Health Care Plan, Inc.</option>
<option value="Group Hospitalization and Medical Services, Inc. (GHMSI)">Group Hospitalization and Medical Services, Inc. (GHMSI)</option>
<option value="Hawaii Medical Service Association (HMSA)">Hawaii Medical Service Association (HMSA)</option>
<option value="Health Advantage">Health Advantage</option>
<option value="HealthKeepers, Inc.">HealthKeepers, Inc.</option>
<option value="Healthwise">Healthwise</option>
<option value="Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Missouri)">Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Missouri)</option>
<option value="Highmark Blue Cross Blue Shield">Highmark Blue Cross Blue Shield</option>
<option value="Highmark Blue Cross Blue Shield of Delaware">Highmark Blue Cross Blue Shield of Delaware</option>
<option value="Highmark Blue Cross Blue Shield of West Virginia">Highmark Blue Cross Blue Shield of West Virginia</option>
<option value="Highmark Blue Shield">Highmark Blue Shield</option>
<option value="HMO Colorado, Inc.">HMO Colorado, Inc.</option>
<option value="HMO Colorado, Inc. d/b/a HMO Nevada, Inc.">HMO Colorado, Inc. d/b/a HMO Nevada, Inc.</option>
<option value="HMO Louisiana, Inc.">HMO Louisiana, Inc.</option>
<option value="HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Missouri)">HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Missouri)</option>
<option value="HMO Partners, Inc.">HMO Partners, Inc.</option>
<option value="Horizon Blue Cross Blue Shield of New Jersey">Horizon Blue Cross Blue Shield of New Jersey</option>
<option value="Independence Administrators">Independence Administrators</option>
<option value="Independence Blue Cross">Independence Blue Cross</option>
<option value="Independence Hospital Indemnity Plan">Independence Hospital Indemnity Plan</option>
<option value="Keystone Health Plan Central, Inc. (KHPC)">Keystone Health Plan Central, Inc. (KHPC)</option>
<option value="Keystone Health Plan East">Keystone Health Plan East</option>
<option value="Keystone Health Plan West">Keystone Health Plan West</option>
<option value="Matthew Thornton Health Plan, Inc.">Matthew Thornton Health Plan, Inc.</option>
<option value="Mountain State Blue Cross Blue Shield">Mountain State Blue Cross Blue Shield</option>
<option value="Premera Blue Cross">Premera Blue Cross</option>
<option value="Premera Blue Cross Blue Shield">Premera Blue Cross Blue Shield</option>
<option value="Premera Blue Cross Blue Shield of Alaska">Premera Blue Cross Blue Shield of Alaska</option>
<option value="QCC Insurance Company">QCC Insurance Company</option>
<option value="Regence BlueCross BlueShield of Oregon">Regence BlueCross BlueShield of Oregon</option>
<option value="Regence BlueCross BlueShield of Utah">Regence BlueCross BlueShield of Utah</option>
<option value="Regence BlueShield">Regence BlueShield</option>
<option value="Regence BlueShield of Idaho">Regence BlueShield of Idaho</option>
<option value="Regence Group Administrators">Regence Group Administrators</option>
<option value="Regence Health Maintenance of Oregon">Regence Health Maintenance of Oregon</option>
<option value="Regence HMO Oregon">Regence HMO Oregon</option>
<option value="Regence Life and Health Insurance Company">Regence Life and Health Insurance Company</option>
<option value="Regence ValueCare">Regence ValueCare</option>
<option value="RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross and Blue Shield">RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Colorado)">Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Colorado)
</option>
<option value="Triple-S Management Corp.">Triple-S Management Corp.</option>
<option value="Triple-S Salud, Inc.">Triple-S Salud, Inc.</option>
<option value="USAble Mutual Insurance Company">USAble Mutual Insurance Company</option>
<option value="Wellmark BCBS of Iowa">Wellmark BCBS of Iowa</option>
<option value="Wellmark BCBS of South Dakota">Wellmark BCBS of South Dakota</option>
<option value="Wellmark Health Plan of Iowa">Wellmark Health Plan of Iowa</option>
<option value="Wellmark Synergy Health Plan">Wellmark Synergy Health Plan</option>
<option value="Wellmark Value Health Plan">Wellmark Value Health Plan</option>
<option value="Wisconsin Collaborative Insurance Company">Wisconsin Collaborative Insurance Company</option>
<option value="Other">Other</option>
</select><span class="k-picker-wrap k-state-default"><input title="" class="form-control k-input ui-autocomplete-input"
autocomplete="off"><a tabindex="-1" title="Show All Items" class="fa fa-chevron-down plan-dropdown-selector k-select"></a></span>
<div class="row health-plan-name-other" style="display: none;">
<div class="col-12">
<label for="employee-health-plan-name-other-{count}" class="control-label">Other Health Plan Name</label>
<input id="employee-health-plan-name-other-{count}" autocomplete="off" class="form-control" type="text" maxlength="200">
</div>
</div>
<span data-valmsg-for="Employee.HealthPlanDetails[{count}].Name" class="text-danger" data-valmsg-replace="true"></span>
<input autocomplete="off" type="text" name="Employee.HealthPlanDetails[{count}].Name" class="health-plan-name" maxlength="200" tabindex="-1" aria-labelledby="employee-health-plan-name-select-{count}">
</div>
<div class="col-md-6">
<label class="control-label">Group #</label>
<input autocomplete="off" type="text" name="Employee.HealthPlanDetails[{count}].GroupNumber" class="form-control employee-group-number" maxlength="100">
<span data-valmsg-for="Employee.HealthPlanDetails[{count}].GroupNumber" class="text-danger" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-md-12">
<label class="control-label required-field-label">Employer Name</label>
<input autocomplete="off" type="text" name="Employee.HealthPlanDetails[{count}].EmployerName" class="form-control employer-name" maxlength="100">
<span data-valmsg-for="Employee.HealthPlanDetails[{count}].EmployerName" class="text-danger" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-md-12">
<label class="control-label">Employer Address</label>
<input autocomplete="off" type="text" name="Employee.HealthPlanDetails[{count}].EmployerMailingAddress" class="form-control employer-address" maxlength="100">
<span data-valmsg-for="Employee.HealthPlanDetails[{count}].EmployerMailingAddress" class="text-danger" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-lg-12 col-xl-4">
<label class="control-label">Subscriber or Member ID</label>
<input autocomplete="off" type="text" name="Employee.HealthPlanDetails[{count}].SubscriberID" class="form-control subscriber-id" value="" maxlength="100">
<span data-valmsg-for="Employee.HealthPlanDetails[{count}].SubscriberID" class="text-danger"></span>
</div>
<div class="col-lg-6 col-xl-4">
<label class="control-label start-date-label">Coverage Start Date</label>
<input autocomplete="off" type="date" name="Employee.HealthPlanDetails[{count}].CoverageStartDate" class="form-control coverageStartDate" value="" placeholder="MM/YYYY">
<span data-valmsg-for="Employee.HealthPlanDetails[{count}].CoverageStartDate" class="text-danger" data-valmsg-replace="true"></span>
</div>
<div class="col-lg-6 col-xl-4">
<label class="control-label">Coverage End Date</label>
<input autocomplete="off" type="date" name="Employee.HealthPlanDetails[{count}].CoverageEndDate" class="form-control coverageEndDate" value="" placeholder="MM/YYYY">
<span data-valmsg-for="Employee.HealthPlanDetails[{count}].CoverageEndDate" class="text-danger" data-valmsg-replace="true"></span>
</div>
</div>
</div>
</div>
</section>
<!-- SECTION 23. -->
<section id="option2section23" class="datalosswarning-on allocation-of-premiums-section">
<div class="allocation-of-premiums-introduction question-group">
<div class="row title-icon">
<div class="col-sm-12">
<h2>
<i class="fal fa-file-contract"></i> Allocation of Premiums
</h2>
</div>
</div>
<div class="row title-desc">
<div class="col-sm-12">
<p> The Settlement provides that payments will be based, in part, on premiums paid for BCBS health insurance or administrative services plans during the relevant periods between February 2008 and October 2020 for fully insured plans,
and between September 2015 and October 2020 for administrative services plans. </p>
<p>The Settlement further provides default formulas for the Claims Administrator to use when determining what percentage of the premium was paid by an employer/entity and what percentage was contributed by its employees/members.</p>
<p> If you accept the <a data-html="true" data-toggle="popover" title="" data-content="100% of premiums for employees who do not file claims are allocated to the claiming employer. When an employee does claim, their premium share is determined through the default formulas, which provide that employees with single coverage are allocated 15% (for fully-insured health insurance) or 18% (for administrative plans) of the total premium paid on their behalf by their employer, and employees with family coverage are allocated 34% (for fully-insured health insurance) or 25% (for administrative plans), with the remainder allocated to the employer. For a full discussion of how these formulas will be used in calculating claims, please refer to the <a href="https://www.bcbssettlement.com/admin/services/connectedapps.cms.extensions/1.0.0.0/asset?id=4a81c01d-f915-4cc4-bec8-3df1d1dda5c5&languageId=1033&inline=true" target="_blank">Plan of Distribution</a> on the Settlement Website." data-trigger="manual" tabindex="0" data-original-title="<i class="fa fa-info-circle"></i> Default Option">
Default option
<i class="fa fa-info-circle"></i>
</a> , you are <b>NOT</b> required to provide any additional data or evidence in support of your claim at this time. If another claimant’s filing affects your claim, you will be provided with an opportunity to respond at a later
date. </p>
<p> If you proceed with the <a data-html="true" data-toggle="popover" title="" data-content="Selecting the alternative option requires that you provide the percentage contribution you believe you contributed for each year that you were enrolled in a BCBS health insurance or administrative services plan. If you choose to apply for an alternative contribution percentage you must supply documentation with this claim form supporting the percentage you claim to have contributed. For a full discussion of how these formulas will be used in calculating claims, please refer to the <a href="https://www.bcbssettlement.com/admin/services/connectedapps.cms.extensions/1.0.0.0/asset?id=4a81c01d-f915-4cc4-bec8-3df1d1dda5c5&languageId=1033&inline=true" target="_blank">Plan of Distribution</a> on the Settlement Website." data-trigger="manual" tabindex="0" data-original-title="<i class="fa fa-info-circle"></i> Alternative Option">
Alternative option
<i class="fa fa-info-circle"></i>
</a> , you must also provide data or evidence to support the alternative contribution percentages you provide. If you select this option, for any time period for which supporting data or evidence is not provided, the Default Option
will be applied. </p>
</div>
</div>
</div>
<div class="allocation-of-premiums-decision question-group">
<input autocomplete="off" type="hidden" value="true" data-val="true" data-val-required="This is required." id="Employee_AllocationOfPremiums_HasAcceptedDefaultAllocationOption"
name="Employee.AllocationOfPremiums.HasAcceptedDefaultAllocationOption">
<div class="allocation-options row">
<div class="col-lg-6">
<div class="allocation-option selected-allocation-option" data-accept-default-allocation="true" tabindex="0">
<div class="wrapper">
<h3>Accept the Default Option</h3>
<div class="icon"><i class="fal fa-check-circle"></i></div>
</div>
</div>
</div>
<div class="col-lg-6">
<div class="allocation-option" data-accept-default-allocation="false" data-toggle="modal" data-target="#employee-flow .alternative-contribution-warning" tabindex="0">
<div class="wrapper">
<h3>Apply for an Alternative Contribution %</h3>
<div class="icon"><i class="fal fa-file-alt"></i></div>
</div>
</div>
</div>
</div>
</div>
<div class="allocation-of-premiums-alternative" style="display:none;">
<div class="row">
<div class="col-md-12">
<div class="default-option-cta">
<div class="row">
<div class="col-md-12">
<div class="wrapper">
<div class="icon">
<div class="circle">
<img src="https://www.bcbssettlement.com/shk/ocf/images/stop-sign.png" alt="Stop Sign">
</div>
</div>
<div class="text">
<p>
<span class="double-underline"><span class="lines"></span><b>STOP:</b></span>
<b>If you want to use the DEFAULT OPTION,</b>
<span class="double-underline"><span class="lines"></span><b>DO NOT</b></span>
<b>FILL OUT THIS SECTION. Instead, click</b>
<a class="allocation-option" data-accept-default-allocation="true" data-dismiss="modal">
<u>HERE</u>.
</a>
</p>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row sub-title">
<div class="col-sm-12">
<div class="sub-num">1</div>
<h5>Alternative Option</h5>
<hr>
</div>
</div>
<div class="row title-desc">
<div class="col-sm-12">
<p> Please state the percentage contribution you believe you contributed for each year that you were enrolled in a BCBS health insurance or administrative services plan. </p>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="allocation-of-premiums-contributions">
<div class="row">
<div class="col-6 col-sm-3">
<label id="employee-allocation-year-header" class="required-field-label">Plan Year</label>
</div>
<div class="col-6 col-sm-5">
<label id="employee-allocation-contribution-header" class="required-field-label">Contribution</label>
</div>
</div>
<hr>
<div id="employee-allocation-of-premiums-contributions-wrapper-0" class="allocation-of-premiums-contributions-wrapper">
<input autocomplete="off" type="hidden" id="Employee.AllocationOfPremiums.AllocationOfPremiumsContributions.Index" name="Employee.AllocationOfPremiums.AllocationOfPremiumsContributions.Index" value="0">
<div class="row mb-2">
<div class="col-6 col-sm-3">
<select class="year form-control" aria-labelledby="employee-allocation-year-header" data-val="true" data-val-range="Invalid Year." data-val-range-max="2020" data-val-range-min="2008"
id="Employee_AllocationOfPremiums_AllocationOfPremiumsContributions_0__Year" name="Employee.AllocationOfPremiums.AllocationOfPremiumsContributions[0].Year" aria-required="true">
<option value=""></option>
<option>2008</option>
<option>2009</option>
<option>2010</option>
<option>2011</option>
<option>2012</option>
<option>2013</option>
<option>2014</option>
<option>2015</option>
<option>2016</option>
<option>2017</option>
<option>2018</option>
<option>2019</option>
<option>2020</option>
</select><span class="text-danger text-wrap field-validation-valid" data-valmsg-for="Employee.AllocationOfPremiums.AllocationOfPremiumsContributions[0].Year" data-valmsg-replace="true"></span>
</div>
<div class="col-6 col-sm-5">
<input autocomplete="off" style="display:inline; width:80%;" type="text" class="allocation-contribution-percent percent form-control" aria-labelledby="employee-allocation-contribution-header" data-val="true"
data-val-number="The field ContributionPercent must be a number." id="Employee_AllocationOfPremiums_AllocationOfPremiumsContributions_0__ContributionPercent"
name="Employee.AllocationOfPremiums.AllocationOfPremiumsContributions[0].ContributionPercent" value="" aria-required="true">
<div style="display:inline;">%</div>
<span class="text-danger text-wrap field-validation-valid" data-valmsg-for="Employee.AllocationOfPremiums.AllocationOfPremiumsContributions[0].ContributionPercent" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-4"></div>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<button type="button" class="add-allocations-of-premiums-year btn btn-primary-outline"><i class="fa fa-plus"></i>ADD ANOTHER YEAR</button>
</div>
</div>
</div>
</div>
</div>
<div class="row sub-title">
<div class="col-sm-12">
<div class="sub-num">2</div>
<h5 id="employee-flow-alternative-allocation-supporting-docs-header" class="alternative-allocation-supporting-docs-header">Upload Supporting Documentation</h5>
<hr>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<p> If you choose to apply for an alternative contribution percentage you must supply documentation with this claim form supporting the percentage you claim to have contributed. If you do not submit supporting documentation the
Default contribution rates will be applied to your claim. </p>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="alert alert-secondary">
<label><input type="checkbox" class="mr-2" data-val="true" data-val-required="You must upload documents now or check the box if you will provide documents later."
id="Employee_AllocationOfPremiums_UploadAlternativeAllocationOfPremiumsDocsLater" name="Employee.AllocationOfPremiums.UploadAlternativeAllocationOfPremiumsDocsLater" value="true"> Check this box if you want to upload your
documents later. </label>
</div>
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.AllocationOfPremiums.UploadAlternativeAllocationOfPremiumsDocsLater" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="supporting-documents-allocation-of-premiums">
<div class="row mb-2">
<div class="col-sm-12">
<p class="text-grey">Supported files include: .jpg, .jpeg, .pdf, .png, .tif, and .tiff. Maximum upload size is 10MB</p>
</div>
</div>
<div id="employee-allocation-of-premiums-file-inputs-0" class="allocation-of-premiums-file-inputs">
<div class="row">
<div class="col-sm-8">
<input type="file" accept=".jpg, .png, .jpeg, .pdf, .tif, .tiff" style="overflow: hidden" class="form-control allocation-of-premiums-input-file" id="employee-allocation-of-premiums-doc_0"
name="employee.AllocationOfPremiumsDoc_0" aria-labelledby="employee-flow-alternative-allocation-supporting-docs-header">
<span data-valmsg-for="employee.AllocationOfPremiumsDoc_0" class="text-danger" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-4">
<a class="clearFileInput"><i class="fa fa-trash"></i> DELETE FILE</a>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<button type="button" class="add-row-allocation-of-premiums-doc btn btn-primary-outline"><i class="fa fa-plus"></i>ADD ANOTHER FILE</button>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="alternative-contribution-warning modal fade" tabindex="-1" role="dialog" aria-labelledby="alternative-contribution-warning-title">
<div class="modal-dialog" role="document">
<div class="modal-content">
<div class="modal-header">
<h3 class="modal-title" id="alternative-contribution-warning-title">
<i class="fal fa-info-circle"></i> Alternative Contribution
</h3>
<button type="button" class="close" data-dismiss="modal" aria-label="Close">
<span aria-hidden="true">×</span>
</button>
</div>
<div class="modal-body">
<p>If you choose to apply for an alternative contribution percentage, you must supply documentation with this claim form supporting the percentage you claim to have contributed. If you do not provide additional documentation, the
Default Option will be applied to your claim.</p>
<p>Selection of the Alternative Option does not ensure a contribution percentage higher than or equal to the Default Option. Your percentage will be dependent on a process that includes a review of all materials submitted pertaining
to your premium.</p>
<p>Are you sure you want to apply for an alternative contribution percentage?</p>
</div>
<div class="modal-footer">
<div class="row mb-2">
<div class="col-sm-12">
<button type="button" class="btn btn-primary-outline allocation-option" data-accept-default-allocation="false" data-dismiss="modal">
<i class="far fa-file-alt"></i>
<span> Continue with alternative option </span>
</button>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<button type="button" class="btn btn-primary allocation-option" data-accept-default-allocation="true" data-dismiss="modal">
<i class="far fa-check-circle"></i>
<span> Switch to the default option </span>
</button>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="add-contribution-template hidden">
<div id="employee-allocation-of-premiums-contributions-wrapper-{count}" class="allocation-of-premiums-contributions-wrapper-hidden">
<div class="row mb-2">
<div class="col-6 col-sm-3">
<select name="Employee.AllocationOfPremiums.AllocationOfPremiumsContributions[{count}].Year" class="year form-control" aria-labelledby="allocation-year-header">
<option value=""></option>
<option>2008</option>
<option>2009</option>
<option>2010</option>
<option>2011</option>
<option>2012</option>
<option>2013</option>
<option>2014</option>
<option>2015</option>
<option>2016</option>
<option>2017</option>
<option>2018</option>
<option>2019</option>
<option>2020</option>
</select><span data-valmsg-for="Employee.AllocationOfPremiums.AllocationOfPremiumsContributions[{count}].Year" class="text-danger text-wrap" data-valmsg-replace="true"></span>
</div>
<div class="col-6 col-sm-5">
<input style="display:inline; width:80%;" autocomplete="off" type="text" name="Employee.AllocationOfPremiums.AllocationOfPremiumsContributions[{count}].ContributionPercent"
class="allocation-contribution-percent percent form-control" aria-labelledby="employee-allocation-contribution-header" data-val="true" data-val-number="The field ContributionPercent must be a number.">
<div style="display:inline;">%</div>
<span data-valmsg-for="Employee.AllocationOfPremiums.AllocationOfPremiumsContributions[{count}].ContributionPercent" class="text-danger text-wrap" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-4 text-left text-sm-right">
<button type="button" data-service-count="{count}" class="btn btn-link remove-allocations-of-premiums-year">
<i class="fa fa-trash"></i> Delete Entry </button>
</div>
</div>
</div>
</div>
<div class="add-documents-template hidden">
<div id="employee-allocation-of-premiums-file-inputs-{count}" class="allocation-of-premiums-file-inputs-hidden">
<div class="row mb-2">
<div class="col-sm-8">
<input type="file" accept=".jpg, .png, .jpeg, .pdf, .tif, .tiff" style="overflow: hidden;" class="form-control allocation-of-premiums-input-file" id="employee-allocation-of-premiums-doc_{count}"
name="employee.AllocationOfPremiumsDoc_{count}" @*="" data-val="true" data-val-shkfilesize="Invalid file size" *@="" aria-labelledby="employee-flow-alternative-allocation-supporting-docs-header">
<span data-valmsg-for="employee.AllocationOfPremiumsDoc_{count}" class="text-danger" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-4">
<button type="button" data-service-count="{count}" class="btn btn-link remove-allocations-of-premiums-input-file">
<i class="fa fa-trash"></i> DELETE FILE </button>
</div>
</div>
</div>
</div>
</section>
<!-- SECTION 24. -->
<section id="option2section24" class="datalosswarning-on">
<div class="question-group">
<div class="row title-icon">
<div class="col-sm-12">
<h2>
<i class="fal fa-money-check-alt"></i> Payment Election
</h2>
</div>
</div>
<div class="row title-desc">
<div class="col-sm-12">
<p> Please let us know how you would like to receive your settlement payment if your claim is deemed valid.</p>
<p> Final determinations of claim amounts will not be made until after processing by the Claims Administrator is complete. Claims will not be paid if the value is equal to or less than $5.00.</p>
<p> Claimants who submit valid, approved claims shall receive a pro-rata percentage of the Net Settlement Fund allocated to their type of coverage (fully-insured or self-funded) based upon their estimated proportion of the cumulative
total of premiums and/or administrative fees paid by all claimants.</p>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="payment-election-wrapper">
<div class="row mb-2">
<div class="col-sm-6">
<label class="required-field-label" for="Employee_Shared_SelectedPaymentOption">Payment Option</label>
<select class="form-control" data-val="true" data-val-required="This is required." id="Employee_Shared_SelectedPaymentOption" name="Employee.Shared.SelectedPaymentOption">
<option value="" selected="">Please Select</option>
<option value="Venmo">Venmo</option>
<option value="PayPal">PayPal</option>
<option value="Pre-paid Card">Pre-paid Card</option>
<option value="Check">Check</option>
</select><span class="text-danger field-validation-valid" data-valmsg-for="Employee.Shared.SelectedPaymentOption" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-6 payment-option-user" style="display:none">
<label for="Employee_Shared_PaymentOptionUsername">Venmo Username</label>
<input autocomplete="off" type="text" class="form-control" aria-labelledby="Employee_Shared_PaymentOptionUsername" data-val="true" data-val-requiredif="This is required." data-val-requiredif-comp="isequalto"
data-val-requiredif-other="SelectedPaymentOption" data-val-requiredif-value="Venmo" id="Employee_Shared_PaymentOptionUsername" name="Employee.Shared.PaymentOptionUsername" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.Shared.PaymentOptionUsername" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-6 payment-option-email" style="display:none">
<label for="Employee_Shared_PayPalEmail">PayPal Email</label>
<input autocomplete="off" type="text" class="form-control" aria-labelledby="Employee_Shared_PayPalEmail" data-val="true" data-val-email="Invalid Email Format." data-val-regex="Invalid Email Format."
data-val-regex-pattern="^[\w!#$%&'*+\-/=?\^_`{|}~]+(\.[\w!#$%&'*+\-/=?\^_`{|}~]+)*@((([\-\w]+\.)+[a-zA-Z0-9\-]{2,})|(([0-9]{1,3}\.){3}[0-9]{1,3}))$" data-val-requiredif="This is required."
data-val-requiredif-comp="isequalto" data-val-requiredif-other="SelectedPaymentOption" data-val-requiredif-value="PayPal" id="Employee_Shared_PayPalEmail" name="Employee.Shared.PayPalEmail" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.Shared.PayPalEmail" data-valmsg-replace="true"></span>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<!-- SECTION 25. -->
<section id="option2section25" class="datalosswarning-on review-section">
<div class="summary-section confirmation-section" id="contact-text" style="display: none">
<div class="row title-icon">
<div class="col-sm-12">
<h2>
<i class="fal fa-check-circle"></i> Confirmation
</h2>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<p>Your claim form has been submitted successfully. Please keep the Claim Number below for your records.</p>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="alert alert-secondary">
<strong>Claim Number:</strong>
<span class="confirmation-claim-number"></span>
</div>
</div>
</div>
<div class="ConfirmationPageUploadedDocuments" style="display: none;">
<div class="row">
<div class="col-md-12">
<h4>Supporting Documentation</h4>
</div>
</div>
</div>
</div>
<button type="button" style="display:none;" class="btn btn-lg btn-primary float-right print-claim">
<span>Print a Copy of Your Claim</span> <i class="fad fa-print"></i>
</button>
<!-- Header -->
<div class="summary-section please-review">
<div class="row title-icon">
<div class="col-sm-12">
<h2>
<i class="fal fa-file-contract"></i> Review
</h2>
</div>
</div>
<div class="row title-desc mb-0">
<div class="col-sm-12"> Please review your claim information below. If you need to make any edits to your claim, you may go back to a page by clicking that section of the progress bar or clicking the Back button at the bottom of the
page. If everything is correct, complete the <a href="#employee-review-signature-header">Signature</a> section at the bottom of the page and click the Submit button. </div>
</div>
</div>
<!-- Contact Info -->
<div class="summary-section">
<div class="row title-icon">
<div class="col-sm-12">
<h2 id="employee-review-contact-info-header" class="review-contact-info-header">
<i class="fal fa-address-card"></i> Subscriber Information
</h2>
</div>
</div>
<div class="row sub-title">
<div class="col-sm-12">
<h5>Mailing Address</h5>
<hr>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="control-label" for="Employee_Shared_MailingStreetLine1_Summary">Street Line 1</label>
<p class="form-control-static" id="Employee_Shared_MailingStreetLine1_Summary"></p>
</div>
<div class="col-sm-6">
<label class="control-label" for="Employee_Shared_MailingStreetLine2_Summary">Street Line 2</label>
<p class="form-control-static" id="Employee_Shared_MailingStreetLine2_Summary"></p>
</div>
</div>
<div class="row mb-2">
<div class="col-sm-6">
<label class="control-label" for="Employee_Shared_MailingCity_Summary">City</label>
<p class="form-control-static" id="Employee_Shared_MailingCity_Summary"></p>
</div>
<div class="col-sm-3 review-field-us">
<label class="control-label" for="Employee_Shared_MailingSubDivision_Summary">State</label>
<p class="form-control-static" id="Employee_Shared_MailingSubDivision_Summary"></p>
</div>
<div class="col-sm-3 review-field-us">
<label class="control-label" for="Employee_Shared_MailingPostalCode_Summary">Zip</label>
<p class="form-control-static" id="Employee_Shared_MailingPostalCode_Summary"></p>
</div>
<div class="col-sm-3 review-field-non-us">
<label class="control-label" for="Employee_Shared_MailingSubDivisionNonUS_Summary">Province</label>
<p class="form-control-static" id="Employee_Shared_MailingSubDivisionNonUS_Summary"></p>
</div>
<div class="col-sm-3 review-field-non-us">
<label class="control-label" for="Employee_Shared_MailingPostalCodeNonUS_Summary">Postal Code</label>
<p class="form-control-static" id="Employee_Shared_MailingPostalCodeNonUS_Summary"></p>
</div>
<div class="col-sm-3 review-field-non-us">
<label class="control-label" for="Employee_Shared_MailingCountry_Summary">Country</label>
<p class="form-control-static" id="Employee_Shared_MailingCountry_Summary"></p>
</div>
</div>
<div class="row sub-title">
<div class="col-sm-12">
<h5>Subscriber Name</h5>
<hr>
</div>
</div>
<div class="row">
<div class="col-sm-3">
<label class="control-label" for="Employee_Shared_FirstName_Summary">First Name</label>
<p class="form-control-static" id="Employee_Shared_FirstName_Summary"></p>
</div>
<div class="col-sm-3">
<label class="control-label" for="Employee_Shared_MiddleInitial_Summary">Middle Initial</label>
<p class="form-control-static" id="Employee_Shared_MiddleInitial_Summary"></p>
</div>
<div class="col-sm-6">
<label class="control-label" for="Employee_Shared_LastName_Summary">Last Name</label>
<p class="form-control-static" id="Employee_Shared_LastName_Summary"></p>
</div>
</div>
<div class="row sub-title">
<div class="col-sm-12">
<h5>Phone Number</h5>
<hr>
</div>
</div>
<div class="row mb-2">
<div class="col-sm-12 review-field-us">
<label class="control-label" for="Employee_Shared_PhoneNumber_Summary">Phone</label>
<p class="form-control-static" id="Employee_Shared_PhoneNumber_Summary"></p>
</div>
<div class="col-sm-12 review-field-non-us">
<label class="control-label" for="Employee_Shared_PhoneNumberNonUS_Summary">Phone</label>
<p class="form-control-static" id="Employee_Shared_PhoneNumberNonUS_Summary"></p>
</div>
</div>
<div class="row sub-title">
<div class="col-sm-12">
<h5>Email Address</h5>
<hr>
</div>
</div>
<div class="row mb-2">
<div class="col-sm-12">
<label class="control-label" for="Employee_Shared_EmailAddress_Summary">Email</label>
<p class="form-control-static" id="Employee_Shared_EmailAddress_Summary"></p>
</div>
</div>
</div>
<!-- Health Plan -->
<div class="summary-section">
<div class="row title-icon">
<div class="col-sm-12">
<h2 id="employee-review-healthplan-header" class="review-healthplan-header">
<i class="fal fa-stethoscope"></i> Health Plan Details
</h2>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="review-healthplans"></div>
</div>
</div>
</div>
<!-- Allocations of Premiums -->
<div class="summary-section">
<div class="row title-icon">
<div class="col-sm-12">
<h2 id="employee-review-allocationofpremiums-header" class="review-allocationofpremiums-header">
<i class="fal fa-file-contract"></i> Allocation of Premiums
</h2>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div class="review-allocation-alternative-selected allocation-option" style="display:none;">
<div class="wrapper">
<h3>Alternative Contribution % Selected</h3>
<div class="icon"><i class="fal fa-file-alt"></i></div>
</div>
</div>
<div class="review-allocation-default-selected allocation-option" style="display:none;">
<div class="wrapper">
<h3>Default Option Selected</h3>
<div class="icon"><i class="fal fa-check-circle"></i></div>
</div>
</div>
</div>
</div>
<div class="review-alternative-option-section" style="display:none;">
<div class="row sub-title">
<div class="col-md-12">
<h5>Alternative Option</h5>
<hr>
</div>
</div>
<div class="employee-review-contributions">
<div class="row">
<div class="col-6 col-sm-3 font-weight-bold">Plan Year</div>
<div class="col-6 col-sm-3 font-weight-bold">Contribution</div>
</div>
<hr>
<div class="review-alternative-options"></div>
</div>
<div class="row sub-title">
<div class="col-md-12">
<h5>Upload Supporting Documentation</h5>
<hr>
</div>
</div>
<div class="row">
<div class="col-md-12 review-supporting-document-summary"></div>
<div class="col-md-12 review-supporting-document-none-selected"></div>
</div>
</div>
<div style="display: none" class="upload-in-progress mt-4">
<div class="row">
<div class="col-md-12 text-center upload-in-progress-title"> Please Wait For Upload </div>
</div>
<div class="row">
<div class="col-md-12 review-supporting-document-list">
</div>
</div>
<div class="failed-upload-block" style="display: none">
<div class="row">
<div class="col-md-12">
<b>Upload Failed For Files</b>
</div>
</div>
<div class="row">
<div class="col-md-12 failed-file-list" style="color:red;"></div>
</div>
</div>
</div>
</div>
<!-- Payment Election -->
<div class="summary-section">
<div class="row title-icon">
<div class="col-sm-12">
<h2 id="employee-review-paymentelection-header" class="review-paymentelection-header">
<i class="fal fa-money-check-alt"></i> Payment Election
</h2>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="control-label" for="Employee_Shared_SelectedPaymentOption">Payment Option</label>
<p class="form-control-static" id="Employee_Shared_SelectedPaymentOption_Summary"></p>
</div>
<div class="col-sm-6 payment-option-user">
<label class="control-label" for="Employee_Shared_PaymentOptionUsername">Venmo Username</label>
<p class="form-control-static" id="Employee_Shared_PaymentOptionUsername_Summary"></p>
</div>
<div class="col-sm-6 payment-option-email">
<label class="control-label" for="Employee_Shared_PayPalEmail">PayPal Email</label>
<p class="form-control-static" id="Employee_Shared_PayPalEmail_Summary"></p>
</div>
</div>
</div>
<!-- Signature -->
<div class="summary-section">
<div class="row title-icon">
<div class="col-sm-12">
<h2 id="employee-review-signature-header" class="review-signature-header">
<i class="fal fa-file-signature"></i> Signature
</h2>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="alert alert-secondary">
<div class="row">
<div class="col-sm-1" style="max-width: 20px;">
<input type="checkbox" data-val="true" data-val-required="This is required." id="Employee_Shared_AffirmSignature" name="Employee.Shared.AffirmSignature" value="true" aria-required="true">
</div>
<div class="col-sm-11">
<label class="control-label required-field-label" for="Employee_Shared_AffirmSignature">By checking this box, I affirm under the laws of the United States and the laws of my State of residence that the information supplied in
this Claim Form by the undersigned is true and correct to the best of my recollection, and that this form was executed on the date set forth below.</label>
</div>
</div>
</div>
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.Shared.AffirmSignature" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-12">
<div class="alert alert-secondary">
<div class="row">
<div class="col-sm-1" style="max-width: 20px;">
<input type="checkbox" data-val="true" data-val-required="This is required." id="Employee_Shared_AffirmMayProvideAdditionalInfo" name="Employee.Shared.AffirmMayProvideAdditionalInfo" value="true" aria-required="true">
</div>
<div class="col-sm-11">
<label class="control-label required-field-label" for="Employee_Shared_AffirmMayProvideAdditionalInfo">By checking this box, I understand that I may be asked to provide supplemental information to the Claims Administrator and/or
Settlement Administrator before my claim will be considered complete and valid.</label>
</div>
</div>
</div>
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.Shared.AffirmMayProvideAdditionalInfo" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-lg-8">
<label class="control-label required-field-label" for="Employee_Shared_Signature">Type your name in the box below to electronically sign your claim</label>
<input autocomplete="off" type="text" class="form-control" maxlength="200" data-val="true" data-val-required="Please type your name above." id="Employee_Shared_Signature" name="Employee.Shared.Signature" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.Shared.Signature" data-valmsg-replace="true"></span>
</div>
<div class="col-lg-4">
<label class="control-label signature-date-label" for="Employee_Shared_SignatureDate">Date</label>
<input class="form-control" readonly="" type="text" id="Employee_Shared_SignatureDate" name="Employee.Shared.SignatureDate" value="10/11/2021">
<span class="text-danger field-validation-valid" data-valmsg-for="Employee.Shared.SignatureDate" data-valmsg-replace="true"></span>
</div>
</div>
</div>
<div class="review-health-plan-template hidden">
<div class="employee-review-healthplan-row-hidden">
<div class="row sub-title">
<div class="col-sm-12">
<h5 class="employee-review-healthplan-title"></h5>
<hr>
</div>
</div>
<div class="row">
<div class="col-sm-3">
<label class="control-label">Health Plan Name</label>
<p class="form-control-static employee-review-health-plan-name"></p>
</div>
<div class="col-sm-3">
<label class="control-label">Group #</label>
<p class="form-control-static employee-review-health-plan-group-number"></p>
</div>
<div class="col-sm-3">
<label class="control-label">Coverage Start Date</label>
<p class="form-control-static employee-review-health-plan-coverage-start-date"></p>
</div>
<div class="col-sm-3">
<label class="control-label">Coverage End Date</label>
<p class="form-control-static employee-review-health-plan-coverage-end-date"></p>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<label class="control-label">Employer Name</label>
<p class="form-control-static employee-review-health-plan-employer-name"></p>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<label class="control-label">Employer Address</label>
<p class="form-control-static employee-review-health-plan-employer-address"></p>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<label class="control-label">Subscriber or Member ID</label>
<p class="form-control-static employee-review-health-plan-subscriber-id"></p>
</div>
</div>
</div>
</div>
<div class="review-alternative-options-template hidden">
<div class="employee-review-allocation-row-hidden">
<div class="row">
<div class="col-6 col-sm-3">
<p class="form-control-static review-alternative-option-year"></p>
</div>
<div class="col-6 col-sm-3">
<p class="form-control-static review-alternative-option-contribution" style="display:inline;"></p>
<p style="display:inline;">%</p>
</div>
</div>
</div>
</div>
<div class="claim-submit-error-text" style="display: none">
<div class="row response-section">
<div class="col-sm-12">
<div class="alert alert-danger">
<h4 class="mb-2">
<i class="fa fa-exclamation-triangle mr-2 claim-submit-error-icon-warning"></i>
<i class="fad fa-spinner-third fa-spin mr-2 claim-submit-error-icon-working" style="display: none;"></i> Error
</h4>
<div class="claim-submit-error-subheader">Your Claim Form Has Not Been Submitted</div>
<div class="claim-submit-error-text-message"></div>
</div>
</div>
</div>
</div>
</section>
</div>
<!-- #endregion -->
<!-- #region OPTION 3. -->
<div id="myself-flow">
<!-- SECTION 31. -->
<section id="option3section31" class="datalosswarning-on">
<div class="question-group">
<div class="form-horizontal">
<div class="row title-icon">
<div class="col-sm-12">
<h2>
<i class="fal fa-address-card"></i> Subscriber Information
</h2>
</div>
</div>
<div class="row">
<div class="col-md-4">
<label class="control-label required-field-label" for="Myself_Shared_FirstName">First Name</label>
<input autocomplete="off" type="text" class="form-control" maxlength="100" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" data-val-required="This is required."
id="Myself_Shared_FirstName" name="Myself.Shared.FirstName" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Myself.Shared.FirstName" data-valmsg-replace="true"></span>
</div>
<div class="col-md-2">
<label class="control-label text-truncate" for="Myself_Shared_MiddleInitial">Middle Initial</label>
<input autocomplete="off" type="text" class="form-control" maxlength="1" data-val="true" data-val-maxlength="This field can only contain one character." data-val-maxlength-max="1" id="Myself_Shared_MiddleInitial"
name="Myself.Shared.MiddleInitial" value="">
</div>
<div class="col-md-6">
<label class="control-label required-field-label" for="Myself_Shared_LastName">Last Name</label>
<input autocomplete="off" type="text" class="form-control" maxlength="100" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" data-val-required="This is required."
id="Myself_Shared_LastName" name="Myself.Shared.LastName" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Myself.Shared.LastName" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-md-6">
<label class="control-label required-field-label" for="Myself_Shared_MailingStreetLine1">Street Line 1</label>
<input autocomplete="off" type="text" class="form-control" maxlength="200" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" data-val-required="This is required."
id="Myself_Shared_MailingStreetLine1" name="Myself.Shared.MailingStreetLine1" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Myself.Shared.MailingStreetLine1" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6">
<label class="control-label" for="Myself_Shared_MailingStreetLine2">Street Line 2</label>
<input autocomplete="off" type="text" class="form-control" maxlength="200" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" id="Myself_Shared_MailingStreetLine2"
name="Myself.Shared.MailingStreetLine2" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Myself.Shared.MailingStreetLine2" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-md-6 col-lg-6">
<label class="control-label required-field-label" for="Myself_Shared_MailingCity">City</label>
<input autocomplete="off" type="text" class="form-control" maxlength="200" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" data-val-required="This is required."
id="Myself_Shared_MailingCity" name="Myself.Shared.MailingCity" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Myself.Shared.MailingCity" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6 col-lg-6 div-country-us">
<label class="control-label required-field-label" for="Myself_Shared_MailingSubDivision">State</label>
<select class="form-control" data-val="true" data-val-requiredif="State or Province is required." data-val-requiredif-comp="isequalto" data-val-requiredif-other="MailingCountry" data-val-requiredif-value="US"
id="Myself_Shared_MailingSubDivision" name="Myself.Shared.MailingSubDivision">
<option value="" selected="selected"></option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AS">American Samoa</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="GU">Guam</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MP">Northern Mariana Islands</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="PR">Puerto Rico</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="VI">U.S. Virgin Islands</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
<option value="AA">AA</option>
<option value="AP">AP</option>
<option value="AE ">AE </option>
</select>
<span class="text-danger field-validation-valid" data-valmsg-for="Myself.Shared.MailingSubDivision" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6 col-lg-6 div-country-non-us" style="display:none">
<label class="control-label required-field-label" for="Myself_Shared_MailingSubDivisionNonUS">Province</label>
<input autocomplete="off" type="text" class="form-control province" maxlength="200" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200"
data-val-requiredif="State or Province is required." data-val-requiredif-comp="isnotequalto" data-val-requiredif-other="MailingCountry" data-val-requiredif-value="US" id="Myself_Shared_MailingSubDivisionNonUS"
name="Myself.Shared.MailingSubDivisionNonUS" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Myself.Shared.MailingSubDivisionNonUS" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-md-6 col-lg-6 div-country-us">
<label class="control-label required-field-label" for="Myself_Shared_MailingPostalCode">Zip</label>
<input autocomplete="off" type="text" class="zip form-control" maxlength="10" data-val="true" data-val-maxlength="This field can contain a maximum of 10 characters." data-val-maxlength-max="10"
data-val-regex="Please enter a five- or nine-digit ZIP code." data-val-regex-pattern="^\d{5}(?:[-\s]?\d{4})?$" data-val-requiredif="ZIP Code is required." data-val-requiredif-comp="isequalto"
data-val-requiredif-other="MailingCountry" data-val-requiredif-value="US" id="Myself_Shared_MailingPostalCode" name="Myself.Shared.MailingPostalCode" value="">
<span class="text-danger zip field-validation-valid" data-valmsg-for="Myself.Shared.MailingPostalCode" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6 col-lg-6 div-country-non-us" style="display:none">
<label class="control-label required-field-label text-truncate" for="Myself_Shared_MailingPostalCodeNonUS">Postal Code</label>
<input autocomplete="off" type="text" class="form-control" maxlength="10" data-val="true" data-val-maxlength="This field can contain a maximum of 10 characters." data-val-maxlength-max="10"
data-val-requiredif="Postal Code is required." data-val-requiredif-comp="isnotequalto" data-val-requiredif-other="MailingCountry" data-val-requiredif-value="US" id="Myself_Shared_MailingPostalCodeNonUS"
name="Myself.Shared.MailingPostalCodeNonUS" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Myself.Shared.MailingPostalCodeNonUS" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6 col-lg-6">
<label class="control-label required-field-label" for="Myself_Shared_MailingCountry">Country</label>
<select class="form-control" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" data-val-required="Country is required." id="Myself_Shared_MailingCountry"
name="Myself.Shared.MailingCountry">
<option value="" selected="selected"></option>
<option value="AD">Andorra</option>
<option value="AF">Afghanistan</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AL">Albania</option>
<option value="AM">Armenia</option>
<option value="AO">Angola</option>
<option value="AR">Argentina</option>
<option value="AT">Austria</option>
<option value="AU">Australia</option>
<option value="AZ">Azerbaijan</option>
<option value="BA">Bosnia and Herzegovina</option>
<option value="BB">Barbados</option>
<option value="BD">Bangladesh</option>
<option value="BE">Belgium</option>
<option value="BF">Burkina Faso</option>
<option value="BG">Bulgaria</option>
<option value="BH">Bahrain</option>
<option value="BI">Burundi</option>
<option value="BJ">Benin</option>
<option value="BN">Brunei Darussalam</option>
<option value="BO">Bolivia(Plurinational State of)</option>
<option value="BR">Brazil</option>
<option value="BS">Bahamas</option>
<option value="BT">Bhutan</option>
<option value="BW">Botswana</option>
<option value="BY">Belarus</option>
<option value="BZ">Belize</option>
<option value="CA">Canada</option>
<option value="CF">Central African Republic</option>
<option value="CG">Congo</option>
<option value="CI">Côte d'Ivoire</option>
<option value="CV">Cape Verde</option>
<option value="CL">Chile</option>
<option value="CM">Cameroon</option>
<option value="CN">China</option>
<option value="CO">Colombia</option>
<option value="CR">Costa Rica</option>
<option value="CU">Cuba</option>
<option value="KM">Comoros</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="DE">Germany</option>
<option value="DJ">Djibouti</option>
<option value="CD">Democratic Republic of the Congo</option>
<option value="DK">Denmark</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="DZ">Algeria</option>
<option value="EC">Ecuador</option>
<option value="EE">Estonia</option>
<option value="EG">Egypt</option>
<option value="ER">Eritrea</option>
<option value="ES">Spain</option>
<option value="ET">Ethiopia</option>
<option value="FI">Finland</option>
<option value="FJ">Fiji</option>
<option value="FM">Micronesia(Federated States of)</option>
<option value="FR">France</option>
<option value="GA">Gabon</option>
<option value="GD">Grenada</option>
<option value="GE">Georgia</option>
<option value="GH">Ghana</option>
<option value="GM">Gambia</option>
<option value="GN">Guinea</option>
<option value="GQ">Equatorial Guinea</option>
<option value="GR">Greece</option>
<option value="GT">Guatemala</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HN">Honduras</option>
<option value="HR">Croatia</option>
<option value="HT">Haiti</option>
<option value="HU">Hungary</option>
<option value="ID">Indonesia</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IN">India</option>
<option value="IQ">Iraq</option>
<option value="IR">Iran(Islamic Republic of)</option>
<option value="IS">Iceland</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JO">Jordan</option>
<option value="JP">Japan</option>
<option value="KE">Kenya</option>
<option value="KG">Kyrgyzstan</option>
<option value="KH">Cambodia</option>
<option value="KI">Kiribati</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="KP">Democratic People's Republic of Korea</option>
<option value="KR">Republic of Korea</option>
<option value="KW">Kuwait</option>
<option value="KZ">Kazakhstan</option>
<option value="LA">Lao People's Democratic Republic</option>
<option value="LB">Lebanon</option>
<option value="LC">Saint Lucia</option>
<option value="LI">Liechtenstein</option>
<option value="LK">Sri Lanka</option>
<option value="LR">Liberia</option>
<option value="LS">Lesotho</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="LV">Latvia</option>
<option value="LY">Libyan Arab Jamahiriya</option>
<option value="MA">Morocco</option>
<option value="MC">Monaco</option>
<option value="MD">Republic of Moldova</option>
<option value="ME">Montenegro</option>
<option value="MG">Madagascar</option>
<option value="MH">Marshall Islands</option>
<option value="MK">The former Yugoslav Republic of Macedonia</option>
<option value="ML">Mali</option>
<option value="MM">Myanmar</option>
<option value="MN">Mongolia</option>
<option value="MR">Mauritania</option>
<option value="MT">Malta</option>
<option value="MU">Mauritius</option>
<option value="MV">Maldives</option>
<option value="MW">Malawi</option>
<option value="MX">Mexico</option>
<option value="MY">Malaysia</option>
<option value="MZ">Mozambique</option>
<option value="NA">Namibia</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NI">Nicaragua</option>
<option value="NL">Netherlands</option>
<option value="NO">Norway</option>
<option value="NP">Nepal</option>
<option value="NR">Nauru</option>
<option value="NZ">New Zealand</option>
<option value="OM">Oman</option>
<option value="PA">Panama</option>
<option value="PE">Peru</option>
<option value="PG">Papua New Guinea</option>
<option value="PH">Philippines</option>
<option value="PK">Pakistan</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PW">Palau</option>
<option value="PY">Paraguay</option>
<option value="QA">Qatar</option>
<option value="RO">Romania</option>
<option value="RS">Serbia</option>
<option value="RU">Russian Federation</option>
<option value="RW">Rwanda</option>
<option value="SA">Saudi Arabia</option>
<option value="SB">Solomon Islands</option>
<option value="SC">Seychelles</option>
<option value="SD">Sudan</option>
<option value="SE">Sweden</option>
<option value="SG">Singapore</option>
<option value="SI">Slovenia</option>
<option value="SK">Slovakia</option>
<option value="SL">Sierra Leone</option>
<option value="SM">San Marino</option>
<option value="SN">Senegal</option>
<option value="SO">Somalia</option>
<option value="SR">Suriname</option>
<option value="ZA">South Africa</option>
<option value="SS">South Sudan</option>
<option value="ST">Sao Tome and Principe</option>
<option value="SV">El Salvador</option>
<option value="SY">Syrian Arab Republic</option>
<option value="SZ">Eswatini</option>
<option value="CH">Switzerland</option>
<option value="TD">Chad</option>
<option value="TG">Togo</option>
<option value="TH">Thailand</option>
<option value="TJ">Tajikistan</option>
<option value="TL">Timor - Leste</option>
<option value="TM">Turkmenistan</option>
<option value="TN">Tunisia</option>
<option value="TO">Tonga</option>
<option value="TR">Turkey</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TV">Tuvalu</option>
<option value="TW">Taiwan</option>
<option value="UA">Ukraine</option>
<option value="UG">Uganda</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom of Great Britain and Northern Ireland</option>
<option value="TZ">United Republic of Tanzania</option>
<option selected="selected" value="US">United States of America</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="VE">Venezuela(Bolivarian Republic of)</option>
<option value="VN">Viet Nam</option>
<option value="VU">Vanuatu</option>
<option value="WS">Samoa</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select>
<span class="text-danger field-validation-valid" data-valmsg-for="Myself.Shared.MailingCountry" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-sm-6 div-country-us">
<label class="control-label required-field-label" for="Myself_Shared_PhoneNumber">Phone</label>
<input autocomplete="off" type="text" maxlength="14" class="form-control phone" data-val="true" data-val-maxlength="Phone number is too long. " data-val-maxlength-max="15" data-val-regex="Invalid phone number format."
data-val-regex-pattern="^(?:\+?1[-. ]?)?\(?([0-9]{3})\)?[-. ]?([0-9]{3})[-. ]?([0-9]{4})[ ]?(x\d{1,5})?$" data-val-requiredif="This is required." data-val-requiredif-comp="isequalto" data-val-requiredif-other="MailingCountry"
data-val-requiredif-value="US" id="Myself_Shared_PhoneNumber" name="Myself.Shared.PhoneNumber" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Myself.Shared.PhoneNumber" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-6 div-country-non-us" style="display:none">
<label class="control-label required-field-label" for="Myself_Shared_PhoneNumberNonUS">Phone</label>
<input autocomplete="off" type="text" maxlength="14" class="form-control phone" data-val="true" data-val-maxlength="LocKey_PhoneNumberMustBeLimitedTo20Characters" data-val-maxlength-max="20" data-val-requiredif="This is required."
data-val-requiredif-comp="isnotequalto" data-val-requiredif-other="MailingCountry" data-val-requiredif-value="US" id="Myself_Shared_PhoneNumberNonUS" name="Myself.Shared.PhoneNumberNonUS" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Myself.Shared.PhoneNumberNonUS" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-6">
<label class="control-label required-field-label" for="Myself_Shared_EmailAddress">Email</label>
<input autocomplete="off" type="text" class="form-control" maxlength="100" data-val="true" data-val-maxlength="Email entered is too long." data-val-maxlength-max="200" data-val-regex="Invalid Email Format."
data-val-regex-pattern="^[\w!#$%&'*+\-/=?\^_`{|}~]+(\.[\w!#$%&'*+\-/=?\^_`{|}~]+)*@((([\-\w]+\.)+[a-zA-Z0-9\-]{2,})|(([0-9]{1,3}\.){3}[0-9]{1,3}))$" data-val-required="This is required." id="Myself_Shared_EmailAddress"
name="Myself.Shared.EmailAddress" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Myself.Shared.EmailAddress" data-valmsg-replace="true"></span>
</div>
</div>
</div>
</div>
</section>
<!-- SECTION 32. -->
<section id="option3section32" class="datalosswarning-on health-plan-details-section">
<div class="question-group">
<div class="form-horizontal">
<div class="row title-icon">
<div class="col-sm-12">
<h2>
<i class="fal fa-stethoscope"></i> Health Plan Details
</h2>
</div>
</div>
<div class="row title-desc">
<div class="col-sm-12"> Please do your best to provide as much information as you can below. While more information will assist the Claims Administrator in processing your claim, only boxes marked with an * are required. </div>
</div>
<div id="health-plan-wrapper-0" class="health-plan-wrapper">
<input autocomplete="off" type="hidden" id="Myself.HealthPlanDetails.Index" name="Myself.HealthPlanDetails.Index" value="0">
<div class="row sub-title">
<div class="col-sm-12">
<div class="row">
<div class="col-sm-8">
<div class="sub-num">1</div>
<h5 class="health-plan-heading">Health Plan Entry</h5>
</div>
<div class="col-sm-4">
<button type="button" data-service-count="0" class="remove-healthplan-btn btn btn-link float-right" style="display: none"><i class="fa fa-trash"></i> Delete Entry</button>
</div>
</div>
<hr>
</div>
</div>
<div class="row mb-3">
<div class="col-md-6 health-plan-name-form-group">
<label for="myself-health-plan-name-select-0" class="control-label">Health Plan Name</label>
<select id="myself-health-plan-name-select-0" class="health-plan-name-select" style="display: none;">
<option value=""></option>
<option value="Anthem Blue Cross Life and Health Insurance Company">Anthem Blue Cross Life and Health Insurance Company</option>
<option value="Anthem Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Kentucky)">Anthem Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Kentucky)</option>
<option value="Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Maine)">Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Maine)</option>
<option value="Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue Cross and Blue Shield (of New Hampshire)">Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue Cross and Blue Shield (of New Hampshire)</option>
<option value="Anthem Health Plans of Virginia, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Virginia)">Anthem Health Plans of Virginia, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Virginia)</option>
<option value="Anthem Health Plans, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Connecticut)">Anthem Health Plans, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Connecticut)</option>
<option value="Anthem Insurance Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana)">Anthem Insurance Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana)</option>
<option value="Arkansas Blue Cross and Blue Shield">Arkansas Blue Cross and Blue Shield</option>
<option value="Blue Benefits Administrators">Blue Benefits Administrators</option>
<option value="Blue Care Network of Michigan">Blue Care Network of Michigan</option>
<option value="Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company">Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company</option>
<option value="Blue Cross & Blue Shield of Rhode Island">Blue Cross & Blue Shield of Rhode Island</option>
<option value="Blue Cross and Blue Shield of Alabama">Blue Cross and Blue Shield of Alabama</option>
<option value="Blue Cross and Blue Shield of Georgia, Inc.">Blue Cross and Blue Shield of Georgia, Inc.</option>
<option value="Blue Cross and Blue Shield of Illinois">Blue Cross and Blue Shield of Illinois</option>
<option value="Blue Cross and Blue Shield of Kansas">Blue Cross and Blue Shield of Kansas</option>
<option value="Blue Cross and Blue Shield of Kansas City">Blue Cross and Blue Shield of Kansas City</option>
<option value="Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.">Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.</option>
<option value="Blue Cross and Blue Shield of Massachusetts, Inc.">Blue Cross and Blue Shield of Massachusetts, Inc.</option>
<option value="Blue Cross and Blue Shield of Minnesota">Blue Cross and Blue Shield of Minnesota</option>
<option value="Blue Cross and Blue Shield of Montana">Blue Cross and Blue Shield of Montana</option>
<option value="Blue Cross and Blue Shield of New Mexico">Blue Cross and Blue Shield of New Mexico</option>
<option value="Blue Cross and Blue Shield of North Carolina">Blue Cross and Blue Shield of North Carolina</option>
<option value="Blue Cross and Blue Shield of Oklahoma">Blue Cross and Blue Shield of Oklahoma</option>
<option value="Blue Cross and Blue Shield of Texas">Blue Cross and Blue Shield of Texas</option>
<option value="Blue Cross and Blue Shield of Vermont">Blue Cross and Blue Shield of Vermont</option>
<option value="Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a Anthem Blue Cross and Blue Shield">Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Blue Cross Blue Shield of Delaware">Blue Cross Blue Shield of Delaware</option>
<option value="Blue Cross Blue Shield of Louisiana">Blue Cross Blue Shield of Louisiana</option>
<option value="Blue Cross Blue Shield of Massachusetts">Blue Cross Blue Shield of Massachusetts</option>
<option value="Blue Cross Blue Shield of Michigan">Blue Cross Blue Shield of Michigan</option>
<option value="Blue Cross Blue Shield of Nebraska">Blue Cross Blue Shield of Nebraska</option>
<option value="Blue Cross Blue Shield of North Dakota">Blue Cross Blue Shield of North Dakota</option>
<option value="Blue Cross Blue Shield of Northeastern Pennsylvania">Blue Cross Blue Shield of Northeastern Pennsylvania</option>
<option value="Blue Cross Blue Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield">Blue Cross Blue Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Blue Cross Blue Shield of Wyoming">Blue Cross Blue Shield of Wyoming</option>
<option value="Blue Cross of California d/b/a Anthem Blue Cross">Blue Cross of California d/b/a Anthem Blue Cross</option>
<option value="Blue Cross of Idaho">Blue Cross of Idaho</option>
<option value="Blue Plus">Blue Plus</option>
<option value="Blue Shield of California">Blue Shield of California</option>
<option value="Blue Shield of California Life & Health Insurance Company">Blue Shield of California Life & Health Insurance Company</option>
<option value="BlueAdvantage Administrators of Arkansas">BlueAdvantage Administrators of Arkansas</option>
<option value="BlueChoice HealthPlan of South Carolina">BlueChoice HealthPlan of South Carolina</option>
<option value="BlueCross BlueShield of Arizona">BlueCross BlueShield of Arizona</option>
<option value="BlueCross BlueShield of Florida, Inc.">BlueCross BlueShield of Florida, Inc.</option>
<option value="BlueCross BlueShield of South Carolina">BlueCross BlueShield of South Carolina</option>
<option value="BlueCross BlueShield of Tennessee">BlueCross BlueShield of Tennessee</option>
<option value="BlueCross BlueShield of Western New York">BlueCross BlueShield of Western New York</option>
<option value="BlueShield of Northeastern New York">BlueShield of Northeastern New York</option>
<option value="California Physicians’ Service dba Blue Shield of California">California Physicians’ Service dba Blue Shield of California</option>
<option value="Capital Advantage Assurance Company (CAAC)">Capital Advantage Assurance Company (CAAC)</option>
<option value="Capital Advantage Insurance Company (CAIC)">Capital Advantage Insurance Company (CAIC)</option>
<option value="Capital BlueCross">Capital BlueCross</option>
<option value="Capital Health Plan, Inc.">Capital Health Plan, Inc.</option>
<option value="CareFirst BlueChoice, Inc.">CareFirst BlueChoice, Inc.</option>
<option value="CareFirst BlueCross BlueShield DC/Montgomery County/Prince George’s County/Virginia">CareFirst BlueCross BlueShield DC/Montgomery County/Prince George’s County/Virginia</option>
<option value="CareFirst BlueCross BlueShield Maryland">CareFirst BlueCross BlueShield Maryland</option>
<option value="CareFirst of Maryland, Inc. (CFMI)">CareFirst of Maryland, Inc. (CFMI)</option>
<option value="CBA Blue (Vermont)">CBA Blue (Vermont)</option>
<option value="CFA LLC">CFA LLC</option>
<option value="Claim Management Services, Inc. d/b/a Anthem Blue Cross and Blue Shield">Claim Management Services, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Community Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Ohio)">Community Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Ohio)</option>
<option value="Compcare Health Services Insurance Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of Wisconsin)">Compcare Health Services Insurance Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of
Wisconsin)</option>
<option value="Empire HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield">Empire HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield</option>
<option value="Empire HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield">Empire HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield</option>
<option value="Excellus BlueCross BlueShield">Excellus BlueCross BlueShield</option>
<option value="First Priority Health">First Priority Health</option>
<option value="First Priority Life">First Priority Life</option>
<option value="Florida Blue">Florida Blue</option>
<option value="Florida Health Care Plan, Inc.">Florida Health Care Plan, Inc.</option>
<option value="Group Hospitalization and Medical Services, Inc. (GHMSI)">Group Hospitalization and Medical Services, Inc. (GHMSI)</option>
<option value="Hawaii Medical Service Association (HMSA)">Hawaii Medical Service Association (HMSA)</option>
<option value="Health Advantage">Health Advantage</option>
<option value="HealthKeepers, Inc.">HealthKeepers, Inc.</option>
<option value="Healthwise">Healthwise</option>
<option value="Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Missouri)">Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Missouri)</option>
<option value="Highmark Blue Cross Blue Shield">Highmark Blue Cross Blue Shield</option>
<option value="Highmark Blue Cross Blue Shield of Delaware">Highmark Blue Cross Blue Shield of Delaware</option>
<option value="Highmark Blue Cross Blue Shield of West Virginia">Highmark Blue Cross Blue Shield of West Virginia</option>
<option value="Highmark Blue Shield">Highmark Blue Shield</option>
<option value="HMO Colorado, Inc.">HMO Colorado, Inc.</option>
<option value="HMO Colorado, Inc. d/b/a HMO Nevada, Inc.">HMO Colorado, Inc. d/b/a HMO Nevada, Inc.</option>
<option value="HMO Louisiana, Inc.">HMO Louisiana, Inc.</option>
<option value="HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Missouri)">HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Missouri)</option>
<option value="HMO Partners, Inc.">HMO Partners, Inc.</option>
<option value="Horizon Blue Cross Blue Shield of New Jersey">Horizon Blue Cross Blue Shield of New Jersey</option>
<option value="Independence Administrators">Independence Administrators</option>
<option value="Independence Blue Cross">Independence Blue Cross</option>
<option value="Independence Hospital Indemnity Plan">Independence Hospital Indemnity Plan</option>
<option value="Keystone Health Plan Central, Inc. (KHPC)">Keystone Health Plan Central, Inc. (KHPC)</option>
<option value="Keystone Health Plan East">Keystone Health Plan East</option>
<option value="Keystone Health Plan West">Keystone Health Plan West</option>
<option value="Matthew Thornton Health Plan, Inc.">Matthew Thornton Health Plan, Inc.</option>
<option value="Mountain State Blue Cross Blue Shield">Mountain State Blue Cross Blue Shield</option>
<option value="Premera Blue Cross">Premera Blue Cross</option>
<option value="Premera Blue Cross Blue Shield">Premera Blue Cross Blue Shield</option>
<option value="Premera Blue Cross Blue Shield of Alaska">Premera Blue Cross Blue Shield of Alaska</option>
<option value="QCC Insurance Company">QCC Insurance Company</option>
<option value="Regence BlueCross BlueShield of Oregon">Regence BlueCross BlueShield of Oregon</option>
<option value="Regence BlueCross BlueShield of Utah">Regence BlueCross BlueShield of Utah</option>
<option value="Regence BlueShield">Regence BlueShield</option>
<option value="Regence BlueShield of Idaho">Regence BlueShield of Idaho</option>
<option value="Regence Group Administrators">Regence Group Administrators</option>
<option value="Regence Health Maintenance of Oregon">Regence Health Maintenance of Oregon</option>
<option value="Regence HMO Oregon">Regence HMO Oregon</option>
<option value="Regence Life and Health Insurance Company">Regence Life and Health Insurance Company</option>
<option value="Regence ValueCare">Regence ValueCare</option>
<option value="RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross and Blue Shield">RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Colorado)">Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Colorado)
</option>
<option value="Triple-S Management Corp.">Triple-S Management Corp.</option>
<option value="Triple-S Salud, Inc.">Triple-S Salud, Inc.</option>
<option value="USAble Mutual Insurance Company">USAble Mutual Insurance Company</option>
<option value="Wellmark BCBS of Iowa">Wellmark BCBS of Iowa</option>
<option value="Wellmark BCBS of South Dakota">Wellmark BCBS of South Dakota</option>
<option value="Wellmark Health Plan of Iowa">Wellmark Health Plan of Iowa</option>
<option value="Wellmark Synergy Health Plan">Wellmark Synergy Health Plan</option>
<option value="Wellmark Value Health Plan">Wellmark Value Health Plan</option>
<option value="Wisconsin Collaborative Insurance Company">Wisconsin Collaborative Insurance Company</option>
<option value="Other">Other</option>
</select><span class="k-picker-wrap k-state-default"><input title="" class="form-control k-input ui-autocomplete-input"
autocomplete="off"><a tabindex="-1" title="Show All Items" class="fa fa-chevron-down plan-dropdown-selector k-select"></a></span>
<div class="row health-plan-name-other" style="display: none;">
<div class="col-12">
<label for="myself-health-plan-name-other-0" class="control-label">Other Health Plan Name</label>
<input id="myself-health-plan-name-other-0" autocomplete="off" class="form-control" type="text" maxlength="200">
</div>
</div>
<span class="text-danger field-validation-valid" data-valmsg-replace="true" data-valmsg-for="Myself.HealthPlanDetails[0].Name"></span>
<input autocomplete="off" type="text" class="health-plan-name" maxlength="200" tabindex="-1" aria-labelledby="myself-health-plan-name-select-0" data-val="true" data-val-maxlength="Plan name must be less than 200 characters."
data-val-maxlength-max="200" id="Myself_HealthPlanDetails_0__Name" name="Myself.HealthPlanDetails[0].Name" value="">
</div>
<div class="col-md-6">
<label class="control-label" for="Myself_HealthPlanDetails_0__GroupNumber">Group #</label>
<input autocomplete="off" type="text" class="form-control myself-group-number" maxlength="100" id="Myself_HealthPlanDetails_0__GroupNumber" name="Myself.HealthPlanDetails[0].GroupNumber" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Myself.HealthPlanDetails[0].GroupNumber" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row mb-3">
<div class="col-lg-12 col-xl-4">
<label class="control-label subscriber-id-label" for="Myself_HealthPlanDetails_0__SubscriberID">Subscriber ID</label>
<input autocomplete="off" type="text" class="form-control myself-subscriber-id" maxlength="100" id="Myself_HealthPlanDetails_0__SubscriberID" name="Myself.HealthPlanDetails[0].SubscriberID" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Myself.HealthPlanDetails[0].SubscriberID" data-valmsg-replace="true"></span>
</div>
<div class="col-lg-6 col-xl-4">
<label class="control-label start-date-label" for="Myself_HealthPlanDetails_0__CoverageStartDate">Coverage Start Date</label>
<span class="k-widget k-datepicker form-control coverageStartDate" style=""><span class="k-picker-wrap k-state-default"><input autocomplete="off" type="text" class="form-control coverageStartDate k-input" value=""
placeholder="MM/YYYY" id="Myself_HealthPlanDetails_0__CoverageStartDate" name="Myself.HealthPlanDetails[0].CoverageStartDate" data-role="datepicker" role="combobox" aria-expanded="false"
aria-owns="Myself_HealthPlanDetails_0__CoverageStartDate_dateview" aria-disabled="false" style="width: 100%;"><span class="k-icon k-i-warning"></span><span unselectable="on" class="k-select" aria-label="select" role="button"
aria-controls="Myself_HealthPlanDetails_0__CoverageStartDate_dateview"><span class="k-icon k-i-calendar"></span></span></span></span>
<span class="text-danger field-validation-valid" data-valmsg-for="Myself.HealthPlanDetails[0].CoverageStartDate" data-valmsg-replace="true"></span>
</div>
<div class="col-lg-6 col-xl-4">
<label class="control-label" for="Myself_HealthPlanDetails_0__CoverageEndDate">Coverage End Date</label>
<span class="k-widget k-datepicker form-control coverageEndDate" style=""><span class="k-picker-wrap k-state-default"><input autocomplete="off" type="text" class="form-control coverageEndDate k-input" value=""
placeholder="MM/YYYY" id="Myself_HealthPlanDetails_0__CoverageEndDate" name="Myself.HealthPlanDetails[0].CoverageEndDate" data-role="datepicker" role="combobox" aria-expanded="false"
aria-owns="Myself_HealthPlanDetails_0__CoverageEndDate_dateview" aria-disabled="false" style="width: 100%;"><span class="k-icon k-i-warning"></span><span unselectable="on" class="k-select" aria-label="select" role="button"
aria-controls="Myself_HealthPlanDetails_0__CoverageEndDate_dateview"><span class="k-icon k-i-calendar"></span></span></span></span>
<span class="text-danger field-validation-valid" data-valmsg-for="Myself.HealthPlanDetails[0].CoverageEndDate" data-valmsg-replace="true"></span>
</div>
</div>
</div>
<hr>
<div class="alert alert-danger" role="alert" id="groupNrRequiredErrMsg" style="display: none">
<i class="fa fa-exclamation-circle"></i> Group # field is required.
</div>
<div class="alert alert-danger" role="alert" id="coverageStartDateRequiredErrMsg" style="display: none">
<i class="fa fa-exclamation-circle"></i> LocKey_CoverageStartDateRequiredErrMsgRequiredErrMsg
</div>
<div class="alert alert-danger" role="alert" id="coverageEndDateRequiredErrMsg" style="display: none">
<i class="fa fa-exclamation-circle"></i> LocKey_CoverageEndDateRequiredErrMsgRequiredErrMsg
</div>
<button type="button" class="add-healthplan-btn btn btn-primary-outline"><i class="fa fa-plus-square"></i> Add another Health Plan</button>
</div>
</div>
<div class="add-healthplan-template hidden">
<div id="health-plan-wrapper-{count}" class="health-plan-wrapper-hidden">
<div class="row sub-title">
<div class="col-sm-12">
<div class="row">
<div class="col-sm-8">
<div class="sub-num"></div>
<h5 class="health-plan-heading">Health Plan Entry</h5>
</div>
<div class="col-sm-4">
<button type="button" data-service-count="{count}" class="remove-healthplan-btn btn btn-link float-right"><i class="fa fa-trash"></i> Delete Entry</button>
</div>
</div>
<hr>
</div>
</div>
<div class="row mb-3">
<div class="col-md-6 health-plan-name-form-group">
<label for="myself-health-plan-name-select-{count}" class="control-label">Health Plan Name</label>
<select id="myself-health-plan-name-select-{count}" class="health-plan-name-select" style="display: none;">
<option value=""></option>
<option value="Anthem Blue Cross Life and Health Insurance Company">Anthem Blue Cross Life and Health Insurance Company</option>
<option value="Anthem Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Kentucky)">Anthem Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Kentucky)</option>
<option value="Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Maine)">Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Maine)</option>
<option value="Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue Cross and Blue Shield (of New Hampshire)">Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue Cross and Blue Shield (of New Hampshire)</option>
<option value="Anthem Health Plans of Virginia, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Virginia)">Anthem Health Plans of Virginia, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Virginia)</option>
<option value="Anthem Health Plans, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Connecticut)">Anthem Health Plans, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Connecticut)</option>
<option value="Anthem Insurance Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana)">Anthem Insurance Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana)</option>
<option value="Arkansas Blue Cross and Blue Shield">Arkansas Blue Cross and Blue Shield</option>
<option value="Blue Benefits Administrators">Blue Benefits Administrators</option>
<option value="Blue Care Network of Michigan">Blue Care Network of Michigan</option>
<option value="Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company">Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company</option>
<option value="Blue Cross & Blue Shield of Rhode Island">Blue Cross & Blue Shield of Rhode Island</option>
<option value="Blue Cross and Blue Shield of Alabama">Blue Cross and Blue Shield of Alabama</option>
<option value="Blue Cross and Blue Shield of Georgia, Inc.">Blue Cross and Blue Shield of Georgia, Inc.</option>
<option value="Blue Cross and Blue Shield of Illinois">Blue Cross and Blue Shield of Illinois</option>
<option value="Blue Cross and Blue Shield of Kansas">Blue Cross and Blue Shield of Kansas</option>
<option value="Blue Cross and Blue Shield of Kansas City">Blue Cross and Blue Shield of Kansas City</option>
<option value="Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.">Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.</option>
<option value="Blue Cross and Blue Shield of Massachusetts, Inc.">Blue Cross and Blue Shield of Massachusetts, Inc.</option>
<option value="Blue Cross and Blue Shield of Minnesota">Blue Cross and Blue Shield of Minnesota</option>
<option value="Blue Cross and Blue Shield of Montana">Blue Cross and Blue Shield of Montana</option>
<option value="Blue Cross and Blue Shield of New Mexico">Blue Cross and Blue Shield of New Mexico</option>
<option value="Blue Cross and Blue Shield of North Carolina">Blue Cross and Blue Shield of North Carolina</option>
<option value="Blue Cross and Blue Shield of Oklahoma">Blue Cross and Blue Shield of Oklahoma</option>
<option value="Blue Cross and Blue Shield of Texas">Blue Cross and Blue Shield of Texas</option>
<option value="Blue Cross and Blue Shield of Vermont">Blue Cross and Blue Shield of Vermont</option>
<option value="Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a Anthem Blue Cross and Blue Shield">Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Blue Cross Blue Shield of Delaware">Blue Cross Blue Shield of Delaware</option>
<option value="Blue Cross Blue Shield of Louisiana">Blue Cross Blue Shield of Louisiana</option>
<option value="Blue Cross Blue Shield of Massachusetts">Blue Cross Blue Shield of Massachusetts</option>
<option value="Blue Cross Blue Shield of Michigan">Blue Cross Blue Shield of Michigan</option>
<option value="Blue Cross Blue Shield of Nebraska">Blue Cross Blue Shield of Nebraska</option>
<option value="Blue Cross Blue Shield of North Dakota">Blue Cross Blue Shield of North Dakota</option>
<option value="Blue Cross Blue Shield of Northeastern Pennsylvania">Blue Cross Blue Shield of Northeastern Pennsylvania</option>
<option value="Blue Cross Blue Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield">Blue Cross Blue Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Blue Cross Blue Shield of Wyoming">Blue Cross Blue Shield of Wyoming</option>
<option value="Blue Cross of California d/b/a Anthem Blue Cross">Blue Cross of California d/b/a Anthem Blue Cross</option>
<option value="Blue Cross of Idaho">Blue Cross of Idaho</option>
<option value="Blue Plus">Blue Plus</option>
<option value="Blue Shield of California">Blue Shield of California</option>
<option value="Blue Shield of California Life & Health Insurance Company">Blue Shield of California Life & Health Insurance Company</option>
<option value="BlueAdvantage Administrators of Arkansas">BlueAdvantage Administrators of Arkansas</option>
<option value="BlueChoice HealthPlan of South Carolina">BlueChoice HealthPlan of South Carolina</option>
<option value="BlueCross BlueShield of Arizona">BlueCross BlueShield of Arizona</option>
<option value="BlueCross BlueShield of Florida, Inc.">BlueCross BlueShield of Florida, Inc.</option>
<option value="BlueCross BlueShield of South Carolina">BlueCross BlueShield of South Carolina</option>
<option value="BlueCross BlueShield of Tennessee">BlueCross BlueShield of Tennessee</option>
<option value="BlueCross BlueShield of Western New York">BlueCross BlueShield of Western New York</option>
<option value="BlueShield of Northeastern New York">BlueShield of Northeastern New York</option>
<option value="California Physicians’ Service dba Blue Shield of California">California Physicians’ Service dba Blue Shield of California</option>
<option value="Capital Advantage Assurance Company (CAAC)">Capital Advantage Assurance Company (CAAC)</option>
<option value="Capital Advantage Insurance Company (CAIC)">Capital Advantage Insurance Company (CAIC)</option>
<option value="Capital BlueCross">Capital BlueCross</option>
<option value="Capital Health Plan, Inc.">Capital Health Plan, Inc.</option>
<option value="CareFirst BlueChoice, Inc.">CareFirst BlueChoice, Inc.</option>
<option value="CareFirst BlueCross BlueShield DC/Montgomery County/Prince George’s County/Virginia">CareFirst BlueCross BlueShield DC/Montgomery County/Prince George’s County/Virginia</option>
<option value="CareFirst BlueCross BlueShield Maryland">CareFirst BlueCross BlueShield Maryland</option>
<option value="CareFirst of Maryland, Inc. (CFMI)">CareFirst of Maryland, Inc. (CFMI)</option>
<option value="CBA Blue (Vermont)">CBA Blue (Vermont)</option>
<option value="CFA LLC">CFA LLC</option>
<option value="Claim Management Services, Inc. d/b/a Anthem Blue Cross and Blue Shield">Claim Management Services, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Community Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Ohio)">Community Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Ohio)</option>
<option value="Compcare Health Services Insurance Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of Wisconsin)">Compcare Health Services Insurance Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of
Wisconsin)</option>
<option value="Empire HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield">Empire HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield</option>
<option value="Empire HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield">Empire HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield</option>
<option value="Excellus BlueCross BlueShield">Excellus BlueCross BlueShield</option>
<option value="First Priority Health">First Priority Health</option>
<option value="First Priority Life">First Priority Life</option>
<option value="Florida Blue">Florida Blue</option>
<option value="Florida Health Care Plan, Inc.">Florida Health Care Plan, Inc.</option>
<option value="Group Hospitalization and Medical Services, Inc. (GHMSI)">Group Hospitalization and Medical Services, Inc. (GHMSI)</option>
<option value="Hawaii Medical Service Association (HMSA)">Hawaii Medical Service Association (HMSA)</option>
<option value="Health Advantage">Health Advantage</option>
<option value="HealthKeepers, Inc.">HealthKeepers, Inc.</option>
<option value="Healthwise">Healthwise</option>
<option value="Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Missouri)">Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Missouri)</option>
<option value="Highmark Blue Cross Blue Shield">Highmark Blue Cross Blue Shield</option>
<option value="Highmark Blue Cross Blue Shield of Delaware">Highmark Blue Cross Blue Shield of Delaware</option>
<option value="Highmark Blue Cross Blue Shield of West Virginia">Highmark Blue Cross Blue Shield of West Virginia</option>
<option value="Highmark Blue Shield">Highmark Blue Shield</option>
<option value="HMO Colorado, Inc.">HMO Colorado, Inc.</option>
<option value="HMO Colorado, Inc. d/b/a HMO Nevada, Inc.">HMO Colorado, Inc. d/b/a HMO Nevada, Inc.</option>
<option value="HMO Louisiana, Inc.">HMO Louisiana, Inc.</option>
<option value="HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Missouri)">HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Missouri)</option>
<option value="HMO Partners, Inc.">HMO Partners, Inc.</option>
<option value="Horizon Blue Cross Blue Shield of New Jersey">Horizon Blue Cross Blue Shield of New Jersey</option>
<option value="Independence Administrators">Independence Administrators</option>
<option value="Independence Blue Cross">Independence Blue Cross</option>
<option value="Independence Hospital Indemnity Plan">Independence Hospital Indemnity Plan</option>
<option value="Keystone Health Plan Central, Inc. (KHPC)">Keystone Health Plan Central, Inc. (KHPC)</option>
<option value="Keystone Health Plan East">Keystone Health Plan East</option>
<option value="Keystone Health Plan West">Keystone Health Plan West</option>
<option value="Matthew Thornton Health Plan, Inc.">Matthew Thornton Health Plan, Inc.</option>
<option value="Mountain State Blue Cross Blue Shield">Mountain State Blue Cross Blue Shield</option>
<option value="Premera Blue Cross">Premera Blue Cross</option>
<option value="Premera Blue Cross Blue Shield">Premera Blue Cross Blue Shield</option>
<option value="Premera Blue Cross Blue Shield of Alaska">Premera Blue Cross Blue Shield of Alaska</option>
<option value="QCC Insurance Company">QCC Insurance Company</option>
<option value="Regence BlueCross BlueShield of Oregon">Regence BlueCross BlueShield of Oregon</option>
<option value="Regence BlueCross BlueShield of Utah">Regence BlueCross BlueShield of Utah</option>
<option value="Regence BlueShield">Regence BlueShield</option>
<option value="Regence BlueShield of Idaho">Regence BlueShield of Idaho</option>
<option value="Regence Group Administrators">Regence Group Administrators</option>
<option value="Regence Health Maintenance of Oregon">Regence Health Maintenance of Oregon</option>
<option value="Regence HMO Oregon">Regence HMO Oregon</option>
<option value="Regence Life and Health Insurance Company">Regence Life and Health Insurance Company</option>
<option value="Regence ValueCare">Regence ValueCare</option>
<option value="RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross and Blue Shield">RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Colorado)">Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Colorado)
</option>
<option value="Triple-S Management Corp.">Triple-S Management Corp.</option>
<option value="Triple-S Salud, Inc.">Triple-S Salud, Inc.</option>
<option value="USAble Mutual Insurance Company">USAble Mutual Insurance Company</option>
<option value="Wellmark BCBS of Iowa">Wellmark BCBS of Iowa</option>
<option value="Wellmark BCBS of South Dakota">Wellmark BCBS of South Dakota</option>
<option value="Wellmark Health Plan of Iowa">Wellmark Health Plan of Iowa</option>
<option value="Wellmark Synergy Health Plan">Wellmark Synergy Health Plan</option>
<option value="Wellmark Value Health Plan">Wellmark Value Health Plan</option>
<option value="Wisconsin Collaborative Insurance Company">Wisconsin Collaborative Insurance Company</option>
<option value="Other">Other</option>
</select><span class="k-picker-wrap k-state-default"><input title="" class="form-control k-input ui-autocomplete-input"
autocomplete="off"><a tabindex="-1" title="Show All Items" class="fa fa-chevron-down plan-dropdown-selector k-select"></a></span>
<div class="row health-plan-name-other" style="display: none;">
<div class="col-12">
<label for="myself-health-plan-name-other-{count}" class="control-label">Other Health Plan Name</label>
<input id="myself-health-plan-name-other-{count}" autocomplete="off" class="form-control" type="text" maxlength="200">
</div>
</div>
<span data-valmsg-for="Myself.HealthPlanDetails[{count}].Name" class="text-danger" data-valmsg-replace="true"></span>
<input autocomplete="off" type="text" name="Myself.HealthPlanDetails[{count}].Name" class="health-plan-name" maxlength="200" tabindex="-1" aria-labelledby="myself-health-plan-name-select-{count}">
</div>
<div class="col-md-6">
<label class="control-label">Group #</label>
<input autocomplete="off" type="text" name="Myself.HealthPlanDetails[{count}].GroupNumber" class="form-control myself-group-number" maxlength="100">
<span data-valmsg-for="Myself.HealthPlanDetails[{count}].GroupNumber" class="text-danger" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row mb-3">
<div class="col-lg-12 col-xl-4">
<label class="control-label subscriber-id-label">Subscriber ID</label>
<input autocomplete="off" type="text" name="Myself.HealthPlanDetails[{count}].SubscriberID" class="form-control myself-subscriber-id" maxlength="100">
<span data-valmsg-for="Myself.HealthPlanDetails[{count}].SubscriberID" class="text-danger" data-valmsg-replace="true"></span>
</div>
<div class="col-lg-6 col-xl-4">
<label class="control-label start-date-label">Coverage Start Date</label>
<input autocomplete="off" type="date" name="Myself.HealthPlanDetails[{count}].CoverageStartDate" class="form-control coverageStartDate" value="" placeholder="MM/YYYY">
<span data-valmsg-for="Myself.HealthPlanDetails[{count}].CoverageStartDate" class="text-danger" data-valmsg-replace="true"></span>
</div>
<div class="col-lg-6 col-xl-4">
<label class="control-label">Coverage End Date</label>
<input autocomplete="off" type="date" name="Myself.HealthPlanDetails[{count}].CoverageEndDate" class="form-control coverageEndDate" value="" placeholder="MM/YYYY">
<span data-valmsg-for="Myself.HealthPlanDetails[{count}].CoverageEndDate" class="text-danger" data-valmsg-replace="true"></span>
</div>
</div>
</div>
</div>
</section>
<!-- SECTION 33. -->
<section id="option3section33" class="datalosswarning-on">
<div class="question-group">
<div class="row title-icon">
<div class="col-sm-12">
<h2>
<i class="fal fa-money-check-alt"></i> Payment Election
</h2>
</div>
</div>
<div class="row title-desc">
<div class="col-sm-12">
<p> Please let us know how you would like to receive your settlement payment if your claim is deemed valid.</p>
<p> Final determinations of claim amounts will not be made until after processing by the Claims Administrator is complete. Claims will not be paid if the value is equal to or less than $5.00.</p>
<p> Claimants who submit valid, approved claims shall receive a pro-rata percentage of the Net Settlement Fund allocated to their type of coverage (fully-insured or self-funded) based upon their estimated proportion of the cumulative
total of premiums and/or administrative fees paid by all claimants.</p>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="payment-election-wrapper">
<div class="row mb-2">
<div class="col-sm-6">
<label class="required-field-label" for="Myself_Shared_SelectedPaymentOption">Payment Option</label>
<select class="form-control" data-val="true" data-val-required="This is required." id="Myself_Shared_SelectedPaymentOption" name="Myself.Shared.SelectedPaymentOption">
<option value="" selected="">Please Select</option>
<option value="Venmo">Venmo</option>
<option value="PayPal">PayPal</option>
<option value="Pre-paid Card">Pre-paid Card</option>
<option value="Check">Check</option>
</select><span class="text-danger field-validation-valid" data-valmsg-for="Myself.Shared.SelectedPaymentOption" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-6 payment-option-user" style="display:none">
<label for="Myself_Shared_PaymentOptionUsername">Venmo Username</label>
<input autocomplete="off" type="text" class="form-control" aria-labelledby="Myself_Shared_PaymentOptionUsername" data-val="true" data-val-requiredif="This is required." data-val-requiredif-comp="isequalto"
data-val-requiredif-other="SelectedPaymentOption" data-val-requiredif-value="Venmo" id="Myself_Shared_PaymentOptionUsername" name="Myself.Shared.PaymentOptionUsername" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Myself.Shared.PaymentOptionUsername" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-6 payment-option-email" style="display:none">
<label for="Myself_Shared_PayPalEmail">PayPal Email</label>
<input autocomplete="off" type="text" class="form-control" aria-labelledby="Myself_Shared_PayPalEmail" data-val="true" data-val-email="Invalid Email Format." data-val-regex="Invalid Email Format."
data-val-regex-pattern="^[\w!#$%&'*+\-/=?\^_`{|}~]+(\.[\w!#$%&'*+\-/=?\^_`{|}~]+)*@((([\-\w]+\.)+[a-zA-Z0-9\-]{2,})|(([0-9]{1,3}\.){3}[0-9]{1,3}))$" data-val-requiredif="This is required."
data-val-requiredif-comp="isequalto" data-val-requiredif-other="SelectedPaymentOption" data-val-requiredif-value="PayPal" id="Myself_Shared_PayPalEmail" name="Myself.Shared.PayPalEmail" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Myself.Shared.PayPalEmail" data-valmsg-replace="true"></span>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<!-- SECTION 34. -->
<section id="option3section34" class="datalosswarning-on review-section">
<div class="summary-section confirmation-section" id="contact-text" style="display: none">
<div class="row title-icon">
<div class="col-sm-12">
<h2>
<i class="fal fa-check-circle"></i> Confirmation
</h2>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<p>Your claim form has been submitted successfully. Please keep the Claim Number below for your records.</p>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="alert alert-secondary">
<strong>Claim Number:</strong>
<span class="confirmation-claim-number"></span>
</div>
</div>
</div>
<div class="ConfirmationPageUploadedDocuments" style="display: none;">
<div class="row">
<div class="col-md-12">
<h4>Supporting Documentation</h4>
</div>
</div>
</div>
</div>
<button type="button" style="display:none;" class="btn btn-lg btn-primary float-right print-claim">
<span>Print a Copy of Your Claim</span> <i class="fad fa-print"></i>
</button>
<!-- Header -->
<div class="summary-section please-review">
<div class="row title-icon">
<div class="col-sm-12">
<h2>
<i class="fal fa-file-contract"></i> Review
</h2>
</div>
</div>
<div class="row title-desc mb-0">
<div class="col-sm-12"> Please review your claim information below. If you need to make any edits to your claim, you may go back to a page by clicking that section of the progress bar or clicking the Back button at the bottom of the
page. If everything is correct, complete the <a href="#myself-review-signature-header">Signature</a> section at the bottom of the page and click the Submit button. </div>
</div>
</div>
<!-- Business Info -->
<div class="summary-section">
<div class="row title-icon">
<div class="col-sm-12">
<h2 id="myself-review-business-info-header" class="review-business-info-header">
<i class="fal fa-building"></i> Subscriber Information
</h2>
</div>
</div>
<div class="row sub-title">
<div class="col-sm-12">
<h5>Mailing Address</h5>
<hr>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="control-label" for="Myself_Shared_MailingStreetLine1_Summary">Street Line 1</label>
<p class="form-control-static" id="Myself_Shared_MailingStreetLine1_Summary"></p>
</div>
<div class="col-sm-6">
<label class="control-label" for="Myself_Shared_MailingStreetLine2_Summary">Street Line 2</label>
<p class="form-control-static" id="Myself_Shared_MailingStreetLine2_Summary"></p>
</div>
</div>
<div class="row mb-2">
<div class="col-sm-6">
<label class="control-label" for="Myself_Shared_MailingCity_Summary">City</label>
<p class="form-control-static" id="Myself_Shared_MailingCity_Summary"></p>
</div>
<div class="col-sm-3 review-field-us">
<label class="control-label" for="Myself_Shared_MailingSubDivision_Summary">State</label>
<p class="form-control-static" id="Myself_Shared_MailingSubDivision_Summary"></p>
</div>
<div class="col-sm-3 review-field-us">
<label class="control-label" for="Myself_Shared_MailingPostalCode_Summary">Zip</label>
<p class="form-control-static" id="Myself_Shared_MailingPostalCode_Summary"></p>
</div>
<div class="col-sm-3 review-field-non-us">
<label class="control-label" for="Myself_Shared_MailingSubDivisionNonUS_Summary">Province</label>
<p class="form-control-static" id="Myself_Shared_MailingSubDivisionNonUS_Summary"></p>
</div>
<div class="col-sm-3 review-field-non-us">
<label class="control-label" for="Myself_Shared_MailingPostalCodeNonUS_Summary">Postal Code</label>
<p class="form-control-static" id="Myself_Shared_MailingPostalCodeNonUS_Summary"></p>
</div>
<div class="col-sm-3 review-field-non-us">
<label class="control-label" for="Myself_Shared_MailingCountry_Summary">Country</label>
<p class="form-control-static" id="Myself_Shared_MailingCountry_Summary"></p>
</div>
</div>
<div class="row sub-title">
<div class="col-sm-12">
<h5>Subscriber Name</h5>
<hr>
</div>
</div>
<div class="row">
<div class="col-sm-3">
<label class="control-label" for="Myself_Shared_FirstName_Summary">First Name</label>
<p class="form-control-static" id="Myself_Shared_FirstName_Summary"></p>
</div>
<div class="col-sm-3">
<label class="control-label" for="Myself_Shared_MiddleInitial_Summary">Middle Initial</label>
<p class="form-control-static" id="Myself_Shared_MiddleInitial_Summary"></p>
</div>
<div class="col-sm-6">
<label class="control-label" for="Myself_Shared_LastName_Summary">Last Name</label>
<p class="form-control-static" id="Myself_Shared_LastName_Summary"></p>
</div>
</div>
<div class="row sub-title">
<div class="col-sm-12">
<h5>Phone Number</h5>
<hr>
</div>
</div>
<div class="row mb-2">
<div class="col-sm-12 review-field-us">
<label class="control-label" for="Myself_Shared_PhoneNumber_Summary">Phone</label>
<p class="form-control-static" id="Myself_Shared_PhoneNumber_Summary"></p>
</div>
<div class="col-sm-12 review-field-non-us">
<label class="control-label" for="Myself_Shared_PhoneNumberNonUS_Summary">Phone</label>
<p class="form-control-static" id="Myself_Shared_PhoneNumberNonUS_Summary"></p>
</div>
</div>
<div class="row sub-title">
<div class="col-sm-12">
<h5>Email Address</h5>
<hr>
</div>
</div>
<div class="row mb-2">
<div class="col-sm-12">
<label class="control-label" for="Myself_Shared_EmailAddress_Summary">Email</label>
<p class="form-control-static" id="Myself_Shared_EmailAddress_Summary"></p>
</div>
</div>
</div>
<!-- Health Plan -->
<div class="summary-section">
<div class="row title-icon">
<div class="col-sm-12">
<h2 id="myself-review-healthplan-header" class="review-healthplan-header">
<i class="fal fa-stethoscope"></i> Health Plan Details
</h2>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="review-healthplans"></div>
</div>
</div>
</div>
<!-- Payment Election -->
<div class="summary-section">
<div class="row title-icon">
<div class="col-sm-12">
<h2 id="myself-review-paymentelection-header" class="review-paymentelection-header">
<i class="fal fa-money-check-alt"></i> Payment Election
</h2>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="control-label" for="Myself_Shared_SelectedPaymentOption">Payment Option</label>
<p class="form-control-static" id="Myself_Shared_SelectedPaymentOption_Summary"></p>
</div>
<div class="col-sm-6 payment-option-user">
<label class="control-label" for="Myself_Shared_PaymentOptionUsername">Venmo Username</label>
<p class="form-control-static" id="Myself_Shared_PaymentOptionUsername_Summary"></p>
</div>
<div class="col-sm-6 payment-option-email">
<label class="control-label" for="Myself_Shared_PayPalEmail">PayPal Email</label>
<p class="form-control-static" id="Myself_Shared_PayPalEmail_Summary"></p>
</div>
</div>
</div>
<!-- Signature -->
<div class="summary-section">
<div class="row title-icon">
<div class="col-sm-12">
<h2 id="myself-review-signature-header" class="review-signature-header">
<i class="fal fa-file-signature"></i> Signature
</h2>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="alert alert-secondary">
<div class="row">
<div class="col-sm-1" style="max-width: 20px;">
<input type="checkbox" data-val="true" data-val-required="This is required." id="Myself_Shared_AffirmSignature" name="Myself.Shared.AffirmSignature" value="true" aria-required="true">
</div>
<div class="col-sm-11">
<label class="control-label required-field-label" for="Myself_Shared_AffirmSignature">By checking this box, I affirm under the laws of the United States and the laws of my State of residence that the information supplied in this
Claim Form by the undersigned is true and correct to the best of my recollection, and that this form was executed on the date set forth below.</label>
</div>
</div>
</div>
<span class="text-danger field-validation-valid" data-valmsg-for="Myself.Shared.AffirmSignature" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-12">
<div class="alert alert-secondary">
<div class="row">
<div class="col-sm-1" style="max-width: 20px;">
<input type="checkbox" data-val="true" data-val-required="This is required." id="Myself_Shared_AffirmMayProvideAdditionalInfo" name="Myself.Shared.AffirmMayProvideAdditionalInfo" value="true" aria-required="true">
</div>
<div class="col-sm-11">
<label class="control-label required-field-label" for="Myself_Shared_AffirmMayProvideAdditionalInfo">By checking this box, I understand that I may be asked to provide supplemental information to the Claims Administrator and/or
Settlement Administrator before my claim will be considered complete and valid.</label>
</div>
</div>
</div>
<span class="text-danger field-validation-valid" data-valmsg-for="Myself.Shared.AffirmMayProvideAdditionalInfo" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-lg-8">
<label class="control-label required-field-label" for="Myself_Shared_Signature">Type your name in the box below to electronically sign your claim</label>
<input autocomplete="off" type="text" class="form-control" maxlength="200" data-val="true" data-val-required="Please type your name above." id="Myself_Shared_Signature" name="Myself.Shared.Signature" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Myself.Shared.Signature" data-valmsg-replace="true"></span>
</div>
<div class="col-lg-4">
<label class="control-label signature-date-label" for="Myself_Shared_SignatureDate">Date</label>
<input class="form-control" readonly="" type="text" id="Myself_Shared_SignatureDate" name="Myself.Shared.SignatureDate" value="10/11/2021">
<span class="text-danger field-validation-valid" data-valmsg-for="Myself.Shared.SignatureDate" data-valmsg-replace="true"></span>
</div>
</div>
</div>
<div class="review-health-plan-template hidden">
<div class="review-healthplan-row-hidden">
<div class="row sub-title">
<div class="col-sm-12">
<h5 class="review-healthplan-title"></h5>
<hr>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="control-label">Health Plan Name</label>
<p class="form-control-static review-health-plan-name"></p>
</div>
<div class="col-sm-6">
<label class="control-label">Group #</label>
<p class="form-control-static review-health-plan-group-number"></p>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="control-label">Subscriber ID</label>
<p class="form-control-static review-health-plan-subscriber-id"></p>
</div>
<div class="col-sm-3">
<label class="control-label">Coverage Start Date</label>
<p class="form-control-static review-health-plan-coverage-start-date"></p>
</div>
<div class="col-sm-3">
<label class="control-label">Coverage End Date</label>
<p class="form-control-static review-health-plan-coverage-end-date"></p>
</div>
</div>
</div>
</div>
<div class="review-alternative-options-template hidden">
<div class="review-allocation-row-hidden">
<div class="row">
<div class="col-6 col-sm-3">
<p class="form-control-static review-alternative-option-year"></p>
</div>
<div class="col-6 col-sm-3">
<p class="form-control-static review-alternative-option-contribution" style="display:inline;"></p>
<p style="display:inline;">%</p>
</div>
</div>
</div>
</div>
<div class="claim-submit-error-text" style="display: none">
<div class="row response-section">
<div class="col-sm-12">
<div class="alert alert-danger">
<h4 class="mb-2">
<i class="fa fa-exclamation-triangle mr-2 claim-submit-error-icon-warning"></i>
<i class="fad fa-spinner-third fa-spin mr-2 claim-submit-error-icon-working" style="display: none;"></i> Error
</h4>
<div class="claim-submit-error-subheader">Your Claim Form Has Not Been Submitted</div>
<div class="claim-submit-error-text-message"></div>
</div>
</div>
</div>
</div>
</section>
<!-- #endregion -->
</div>
<!-- #region OPTION 4. -->
<!-- SECTION 41. -->
<div id="both-flow">
<section id="option4section41" class="datalosswarning-on">
<div class="question-group">
<div class="form-horizontal">
<div class="row title-icon">
<div class="col-sm-12">
<h2>
<i class="fal fa-address-card"></i> Subscriber Information
</h2>
</div>
</div>
<div class="row">
<div class="col-md-4">
<label class="control-label required-field-label" for="Both_Shared_FirstName">First Name</label>
<input autocomplete="off" type="text" class="form-control" maxlength="100" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" data-val-required="This is required."
id="Both_Shared_FirstName" name="Both.Shared.FirstName" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Both.Shared.FirstName" data-valmsg-replace="true"></span>
</div>
<div class="col-md-2">
<label class="control-label text-truncate" for="Both_Shared_MiddleInitial">Middle Initial</label>
<input autocomplete="off" type="text" class="form-control" maxlength="1" data-val="true" data-val-maxlength="This field can only contain one character." data-val-maxlength-max="1" id="Both_Shared_MiddleInitial"
name="Both.Shared.MiddleInitial" value="">
</div>
<div class="col-md-6">
<label class="control-label required-field-label" for="Both_Shared_LastName">Last Name</label>
<input autocomplete="off" type="text" class="form-control" maxlength="100" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" data-val-required="This is required."
id="Both_Shared_LastName" name="Both.Shared.LastName" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Both.Shared.LastName" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-md-6">
<label class="control-label required-field-label" for="Both_Shared_MailingStreetLine1">Street Line 1</label>
<input autocomplete="off" type="text" class="form-control" maxlength="200" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" data-val-required="This is required."
id="Both_Shared_MailingStreetLine1" name="Both.Shared.MailingStreetLine1" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Both.Shared.MailingStreetLine1" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6">
<label class="control-label" for="Both_Shared_MailingStreetLine2">Street Line 2</label>
<input autocomplete="off" type="text" class="form-control" maxlength="200" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" id="Both_Shared_MailingStreetLine2"
name="Both.Shared.MailingStreetLine2" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Both.Shared.MailingStreetLine2" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-md-6 col-lg-6">
<label class="control-label required-field-label" for="Both_Shared_MailingCity">City</label>
<input autocomplete="off" type="text" class="form-control" maxlength="200" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" data-val-required="This is required."
id="Both_Shared_MailingCity" name="Both.Shared.MailingCity" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Both.Shared.MailingCity" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6 col-lg-6 div-country-us">
<label class="control-label required-field-label" for="Both_Shared_MailingSubDivision">State</label>
<select class="form-control" data-val="true" data-val-requiredif="State or Province is required." data-val-requiredif-comp="isequalto" data-val-requiredif-other="MailingCountry" data-val-requiredif-value="US"
id="Both_Shared_MailingSubDivision" name="Both.Shared.MailingSubDivision">
<option value="" selected="selected"></option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AS">American Samoa</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="GU">Guam</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MP">Northern Mariana Islands</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="PR">Puerto Rico</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="VI">U.S. Virgin Islands</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
<option value="AA">AA</option>
<option value="AP">AP</option>
<option value="AE ">AE </option>
</select>
<span class="text-danger field-validation-valid" data-valmsg-for="Both.Shared.MailingSubDivision" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6 col-lg-6 div-country-non-us" style="display:none">
<label class="control-label required-field-label" for="Both_Shared_MailingSubDivisionNonUS">Province</label>
<input autocomplete="off" type="text" class="form-control province" maxlength="200" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200"
data-val-requiredif="State or Province is required." data-val-requiredif-comp="isnotequalto" data-val-requiredif-other="MailingCountry" data-val-requiredif-value="US" id="Both_Shared_MailingSubDivisionNonUS"
name="Both.Shared.MailingSubDivisionNonUS" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Both.Shared.MailingSubDivisionNonUS" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-md-6 col-lg-6 div-country-us">
<label class="control-label required-field-label" for="Both_Shared_MailingPostalCode">Zip</label>
<input autocomplete="off" type="text" class="zip form-control" maxlength="10" data-val="true" data-val-maxlength="This field can contain a maximum of 10 characters." data-val-maxlength-max="10"
data-val-regex="Please enter a five- or nine-digit ZIP code." data-val-regex-pattern="^\d{5}(?:[-\s]?\d{4})?$" data-val-requiredif="ZIP Code is required." data-val-requiredif-comp="isequalto"
data-val-requiredif-other="MailingCountry" data-val-requiredif-value="US" id="Both_Shared_MailingPostalCode" name="Both.Shared.MailingPostalCode" value="">
<span class="text-danger zip field-validation-valid" data-valmsg-for="Both.Shared.MailingPostalCode" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6 col-lg-6 div-country-non-us" style="display:none">
<label class="control-label required-field-label text-truncate" for="Both_Shared_MailingPostalCodeNonUS">Postal Code</label>
<input autocomplete="off" type="text" class="form-control" maxlength="10" data-val="true" data-val-maxlength="This field can contain a maximum of 10 characters." data-val-maxlength-max="10"
data-val-requiredif="Postal Code is required." data-val-requiredif-comp="isnotequalto" data-val-requiredif-other="MailingCountry" data-val-requiredif-value="US" id="Both_Shared_MailingPostalCodeNonUS"
name="Both.Shared.MailingPostalCodeNonUS" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Both.Shared.MailingPostalCodeNonUS" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6 col-lg-6">
<label class="control-label required-field-label" for="Both_Shared_MailingCountry">Country</label>
<select class="form-control" data-val="true" data-val-maxlength="This field can contain a maximum of 200 characters." data-val-maxlength-max="200" data-val-required="Country is required." id="Both_Shared_MailingCountry"
name="Both.Shared.MailingCountry">
<option value="" selected="selected"></option>
<option value="AD">Andorra</option>
<option value="AF">Afghanistan</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AL">Albania</option>
<option value="AM">Armenia</option>
<option value="AO">Angola</option>
<option value="AR">Argentina</option>
<option value="AT">Austria</option>
<option value="AU">Australia</option>
<option value="AZ">Azerbaijan</option>
<option value="BA">Bosnia and Herzegovina</option>
<option value="BB">Barbados</option>
<option value="BD">Bangladesh</option>
<option value="BE">Belgium</option>
<option value="BF">Burkina Faso</option>
<option value="BG">Bulgaria</option>
<option value="BH">Bahrain</option>
<option value="BI">Burundi</option>
<option value="BJ">Benin</option>
<option value="BN">Brunei Darussalam</option>
<option value="BO">Bolivia(Plurinational State of)</option>
<option value="BR">Brazil</option>
<option value="BS">Bahamas</option>
<option value="BT">Bhutan</option>
<option value="BW">Botswana</option>
<option value="BY">Belarus</option>
<option value="BZ">Belize</option>
<option value="CA">Canada</option>
<option value="CF">Central African Republic</option>
<option value="CG">Congo</option>
<option value="CI">Côte d'Ivoire</option>
<option value="CV">Cape Verde</option>
<option value="CL">Chile</option>
<option value="CM">Cameroon</option>
<option value="CN">China</option>
<option value="CO">Colombia</option>
<option value="CR">Costa Rica</option>
<option value="CU">Cuba</option>
<option value="KM">Comoros</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="DE">Germany</option>
<option value="DJ">Djibouti</option>
<option value="CD">Democratic Republic of the Congo</option>
<option value="DK">Denmark</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="DZ">Algeria</option>
<option value="EC">Ecuador</option>
<option value="EE">Estonia</option>
<option value="EG">Egypt</option>
<option value="ER">Eritrea</option>
<option value="ES">Spain</option>
<option value="ET">Ethiopia</option>
<option value="FI">Finland</option>
<option value="FJ">Fiji</option>
<option value="FM">Micronesia(Federated States of)</option>
<option value="FR">France</option>
<option value="GA">Gabon</option>
<option value="GD">Grenada</option>
<option value="GE">Georgia</option>
<option value="GH">Ghana</option>
<option value="GM">Gambia</option>
<option value="GN">Guinea</option>
<option value="GQ">Equatorial Guinea</option>
<option value="GR">Greece</option>
<option value="GT">Guatemala</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HN">Honduras</option>
<option value="HR">Croatia</option>
<option value="HT">Haiti</option>
<option value="HU">Hungary</option>
<option value="ID">Indonesia</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IN">India</option>
<option value="IQ">Iraq</option>
<option value="IR">Iran(Islamic Republic of)</option>
<option value="IS">Iceland</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JO">Jordan</option>
<option value="JP">Japan</option>
<option value="KE">Kenya</option>
<option value="KG">Kyrgyzstan</option>
<option value="KH">Cambodia</option>
<option value="KI">Kiribati</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="KP">Democratic People's Republic of Korea</option>
<option value="KR">Republic of Korea</option>
<option value="KW">Kuwait</option>
<option value="KZ">Kazakhstan</option>
<option value="LA">Lao People's Democratic Republic</option>
<option value="LB">Lebanon</option>
<option value="LC">Saint Lucia</option>
<option value="LI">Liechtenstein</option>
<option value="LK">Sri Lanka</option>
<option value="LR">Liberia</option>
<option value="LS">Lesotho</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="LV">Latvia</option>
<option value="LY">Libyan Arab Jamahiriya</option>
<option value="MA">Morocco</option>
<option value="MC">Monaco</option>
<option value="MD">Republic of Moldova</option>
<option value="ME">Montenegro</option>
<option value="MG">Madagascar</option>
<option value="MH">Marshall Islands</option>
<option value="MK">The former Yugoslav Republic of Macedonia</option>
<option value="ML">Mali</option>
<option value="MM">Myanmar</option>
<option value="MN">Mongolia</option>
<option value="MR">Mauritania</option>
<option value="MT">Malta</option>
<option value="MU">Mauritius</option>
<option value="MV">Maldives</option>
<option value="MW">Malawi</option>
<option value="MX">Mexico</option>
<option value="MY">Malaysia</option>
<option value="MZ">Mozambique</option>
<option value="NA">Namibia</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NI">Nicaragua</option>
<option value="NL">Netherlands</option>
<option value="NO">Norway</option>
<option value="NP">Nepal</option>
<option value="NR">Nauru</option>
<option value="NZ">New Zealand</option>
<option value="OM">Oman</option>
<option value="PA">Panama</option>
<option value="PE">Peru</option>
<option value="PG">Papua New Guinea</option>
<option value="PH">Philippines</option>
<option value="PK">Pakistan</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PW">Palau</option>
<option value="PY">Paraguay</option>
<option value="QA">Qatar</option>
<option value="RO">Romania</option>
<option value="RS">Serbia</option>
<option value="RU">Russian Federation</option>
<option value="RW">Rwanda</option>
<option value="SA">Saudi Arabia</option>
<option value="SB">Solomon Islands</option>
<option value="SC">Seychelles</option>
<option value="SD">Sudan</option>
<option value="SE">Sweden</option>
<option value="SG">Singapore</option>
<option value="SI">Slovenia</option>
<option value="SK">Slovakia</option>
<option value="SL">Sierra Leone</option>
<option value="SM">San Marino</option>
<option value="SN">Senegal</option>
<option value="SO">Somalia</option>
<option value="SR">Suriname</option>
<option value="ZA">South Africa</option>
<option value="SS">South Sudan</option>
<option value="ST">Sao Tome and Principe</option>
<option value="SV">El Salvador</option>
<option value="SY">Syrian Arab Republic</option>
<option value="SZ">Eswatini</option>
<option value="CH">Switzerland</option>
<option value="TD">Chad</option>
<option value="TG">Togo</option>
<option value="TH">Thailand</option>
<option value="TJ">Tajikistan</option>
<option value="TL">Timor - Leste</option>
<option value="TM">Turkmenistan</option>
<option value="TN">Tunisia</option>
<option value="TO">Tonga</option>
<option value="TR">Turkey</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TV">Tuvalu</option>
<option value="TW">Taiwan</option>
<option value="UA">Ukraine</option>
<option value="UG">Uganda</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom of Great Britain and Northern Ireland</option>
<option value="TZ">United Republic of Tanzania</option>
<option selected="selected" value="US">United States of America</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="VE">Venezuela(Bolivarian Republic of)</option>
<option value="VN">Viet Nam</option>
<option value="VU">Vanuatu</option>
<option value="WS">Samoa</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select>
<span class="text-danger field-validation-valid" data-valmsg-for="Both.Shared.MailingCountry" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-sm-6 div-country-us">
<label class="control-label required-field-label" for="Both_Shared_PhoneNumber">Phone</label>
<input autocomplete="off" type="text" maxlength="14" class="form-control phone" data-val="true" data-val-maxlength="Phone number is too long. " data-val-maxlength-max="15" data-val-regex="Invalid phone number format."
data-val-regex-pattern="^(?:\+?1[-. ]?)?\(?([0-9]{3})\)?[-. ]?([0-9]{3})[-. ]?([0-9]{4})[ ]?(x\d{1,5})?$" data-val-requiredif="This is required." data-val-requiredif-comp="isequalto" data-val-requiredif-other="MailingCountry"
data-val-requiredif-value="US" id="Both_Shared_PhoneNumber" name="Both.Shared.PhoneNumber" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Both.Shared.PhoneNumber" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-6 div-country-non-us" style="display:none">
<label class="control-label required-field-label" for="Both_Shared_PhoneNumberNonUS">Phone</label>
<input autocomplete="off" type="text" maxlength="14" class="form-control phone" data-val="true" data-val-maxlength="LocKey_PhoneNumberMustBeLimitedTo20Characters" data-val-maxlength-max="20" data-val-requiredif="This is required."
data-val-requiredif-comp="isnotequalto" data-val-requiredif-other="MailingCountry" data-val-requiredif-value="US" id="Both_Shared_PhoneNumberNonUS" name="Both.Shared.PhoneNumberNonUS" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Both.Shared.PhoneNumberNonUS" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-6">
<label class="control-label required-field-label" for="Both_Shared_EmailAddress">Email</label>
<input autocomplete="off" type="text" class="form-control" maxlength="100" data-val="true" data-val-maxlength="Email entered is too long." data-val-maxlength-max="200" data-val-regex="Invalid Email Format."
data-val-regex-pattern="^[\w!#$%&'*+\-/=?\^_`{|}~]+(\.[\w!#$%&'*+\-/=?\^_`{|}~]+)*@((([\-\w]+\.)+[a-zA-Z0-9\-]{2,})|(([0-9]{1,3}\.){3}[0-9]{1,3}))$" data-val-required="This is required." id="Both_Shared_EmailAddress"
name="Both.Shared.EmailAddress" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Both.Shared.EmailAddress" data-valmsg-replace="true"></span>
</div>
</div>
</div>
</div>
</section>
<section id="option4section42" class="datalosswarning-on health-plan-details-section">
<div class="question-group">
<div class="form-horizontal">
<div class="row title-icon">
<div class="col-sm-12">
<h2>
<i class="fal fa-stethoscope"></i> Health Plan Details
</h2>
</div>
</div>
<div class="row title-desc">
<div class="col-sm-12"> Please do your best to provide as much information as you can below. While more information will assist the Claims Administrator in processing your claim, only boxes marked with an * are required. </div>
</div>
<div class="both-health-plans">
<div id="both-employee-health-plan-wrapper-0" class="health-plan-wrapper" data-plan-type="employee">
<input type="hidden" id="Both.EmployeeHealthPlanDetails.Index" name="Both.EmployeeHealthPlanDetails.Index" value="0">
<div class="row sub-title">
<div class="col-sm-12">
<div class="row">
<div class="col-sm-8">
<div class="sub-num">1</div>
<h5 class="health-plan-heading">Employee Health Plan Entry</h5>
</div>
</div>
<hr>
</div>
</div>
<div class="row">
<div class="col-md-6 health-plan-name-form-group">
<label for="both-health-plan-name-select-0" class="control-label">Health Plan Name</label>
<select id="both-health-plan-name-select-0" class="health-plan-name-select" style="display: none;">
<option value=""></option>
<option value="Anthem Blue Cross Life and Health Insurance Company">Anthem Blue Cross Life and Health Insurance Company</option>
<option value="Anthem Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Kentucky)">Anthem Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Kentucky)</option>
<option value="Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Maine)">Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Maine)</option>
<option value="Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue Cross and Blue Shield (of New Hampshire)">Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue Cross and Blue Shield (of New Hampshire)
</option>
<option value="Anthem Health Plans of Virginia, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Virginia)">Anthem Health Plans of Virginia, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Virginia)</option>
<option value="Anthem Health Plans, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Connecticut)">Anthem Health Plans, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Connecticut)</option>
<option value="Anthem Insurance Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana)">Anthem Insurance Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana)</option>
<option value="Arkansas Blue Cross and Blue Shield">Arkansas Blue Cross and Blue Shield</option>
<option value="Blue Benefits Administrators">Blue Benefits Administrators</option>
<option value="Blue Care Network of Michigan">Blue Care Network of Michigan</option>
<option value="Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company">Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company</option>
<option value="Blue Cross & Blue Shield of Rhode Island">Blue Cross & Blue Shield of Rhode Island</option>
<option value="Blue Cross and Blue Shield of Alabama">Blue Cross and Blue Shield of Alabama</option>
<option value="Blue Cross and Blue Shield of Georgia, Inc.">Blue Cross and Blue Shield of Georgia, Inc.</option>
<option value="Blue Cross and Blue Shield of Illinois">Blue Cross and Blue Shield of Illinois</option>
<option value="Blue Cross and Blue Shield of Kansas">Blue Cross and Blue Shield of Kansas</option>
<option value="Blue Cross and Blue Shield of Kansas City">Blue Cross and Blue Shield of Kansas City</option>
<option value="Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.">Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.</option>
<option value="Blue Cross and Blue Shield of Massachusetts, Inc.">Blue Cross and Blue Shield of Massachusetts, Inc.</option>
<option value="Blue Cross and Blue Shield of Minnesota">Blue Cross and Blue Shield of Minnesota</option>
<option value="Blue Cross and Blue Shield of Montana">Blue Cross and Blue Shield of Montana</option>
<option value="Blue Cross and Blue Shield of New Mexico">Blue Cross and Blue Shield of New Mexico</option>
<option value="Blue Cross and Blue Shield of North Carolina">Blue Cross and Blue Shield of North Carolina</option>
<option value="Blue Cross and Blue Shield of Oklahoma">Blue Cross and Blue Shield of Oklahoma</option>
<option value="Blue Cross and Blue Shield of Texas">Blue Cross and Blue Shield of Texas</option>
<option value="Blue Cross and Blue Shield of Vermont">Blue Cross and Blue Shield of Vermont</option>
<option value="Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a Anthem Blue Cross and Blue Shield">Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Blue Cross Blue Shield of Delaware">Blue Cross Blue Shield of Delaware</option>
<option value="Blue Cross Blue Shield of Louisiana">Blue Cross Blue Shield of Louisiana</option>
<option value="Blue Cross Blue Shield of Massachusetts">Blue Cross Blue Shield of Massachusetts</option>
<option value="Blue Cross Blue Shield of Michigan">Blue Cross Blue Shield of Michigan</option>
<option value="Blue Cross Blue Shield of Nebraska">Blue Cross Blue Shield of Nebraska</option>
<option value="Blue Cross Blue Shield of North Dakota">Blue Cross Blue Shield of North Dakota</option>
<option value="Blue Cross Blue Shield of Northeastern Pennsylvania">Blue Cross Blue Shield of Northeastern Pennsylvania</option>
<option value="Blue Cross Blue Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield">Blue Cross Blue Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Blue Cross Blue Shield of Wyoming">Blue Cross Blue Shield of Wyoming</option>
<option value="Blue Cross of California d/b/a Anthem Blue Cross">Blue Cross of California d/b/a Anthem Blue Cross</option>
<option value="Blue Cross of Idaho">Blue Cross of Idaho</option>
<option value="Blue Plus">Blue Plus</option>
<option value="Blue Shield of California">Blue Shield of California</option>
<option value="Blue Shield of California Life & Health Insurance Company">Blue Shield of California Life & Health Insurance Company</option>
<option value="BlueAdvantage Administrators of Arkansas">BlueAdvantage Administrators of Arkansas</option>
<option value="BlueChoice HealthPlan of South Carolina">BlueChoice HealthPlan of South Carolina</option>
<option value="BlueCross BlueShield of Arizona">BlueCross BlueShield of Arizona</option>
<option value="BlueCross BlueShield of Florida, Inc.">BlueCross BlueShield of Florida, Inc.</option>
<option value="BlueCross BlueShield of South Carolina">BlueCross BlueShield of South Carolina</option>
<option value="BlueCross BlueShield of Tennessee">BlueCross BlueShield of Tennessee</option>
<option value="BlueCross BlueShield of Western New York">BlueCross BlueShield of Western New York</option>
<option value="BlueShield of Northeastern New York">BlueShield of Northeastern New York</option>
<option value="California Physicians’ Service dba Blue Shield of California">California Physicians’ Service dba Blue Shield of California</option>
<option value="Capital Advantage Assurance Company (CAAC)">Capital Advantage Assurance Company (CAAC)</option>
<option value="Capital Advantage Insurance Company (CAIC)">Capital Advantage Insurance Company (CAIC)</option>
<option value="Capital BlueCross">Capital BlueCross</option>
<option value="Capital Health Plan, Inc.">Capital Health Plan, Inc.</option>
<option value="CareFirst BlueChoice, Inc.">CareFirst BlueChoice, Inc.</option>
<option value="CareFirst BlueCross BlueShield DC/Montgomery County/Prince George’s County/Virginia">CareFirst BlueCross BlueShield DC/Montgomery County/Prince George’s County/Virginia</option>
<option value="CareFirst BlueCross BlueShield Maryland">CareFirst BlueCross BlueShield Maryland</option>
<option value="CareFirst of Maryland, Inc. (CFMI)">CareFirst of Maryland, Inc. (CFMI)</option>
<option value="CBA Blue (Vermont)">CBA Blue (Vermont)</option>
<option value="CFA LLC">CFA LLC</option>
<option value="Claim Management Services, Inc. d/b/a Anthem Blue Cross and Blue Shield">Claim Management Services, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Community Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Ohio)">Community Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Ohio)</option>
<option value="Compcare Health Services Insurance Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of Wisconsin)">Compcare Health Services Insurance Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of
Wisconsin)</option>
<option value="Empire HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield">Empire HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield</option>
<option value="Empire HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield">Empire HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield</option>
<option value="Excellus BlueCross BlueShield">Excellus BlueCross BlueShield</option>
<option value="First Priority Health">First Priority Health</option>
<option value="First Priority Life">First Priority Life</option>
<option value="Florida Blue">Florida Blue</option>
<option value="Florida Health Care Plan, Inc.">Florida Health Care Plan, Inc.</option>
<option value="Group Hospitalization and Medical Services, Inc. (GHMSI)">Group Hospitalization and Medical Services, Inc. (GHMSI)</option>
<option value="Hawaii Medical Service Association (HMSA)">Hawaii Medical Service Association (HMSA)</option>
<option value="Health Advantage">Health Advantage</option>
<option value="HealthKeepers, Inc.">HealthKeepers, Inc.</option>
<option value="Healthwise">Healthwise</option>
<option value="Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Missouri)">Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Missouri)</option>
<option value="Highmark Blue Cross Blue Shield">Highmark Blue Cross Blue Shield</option>
<option value="Highmark Blue Cross Blue Shield of Delaware">Highmark Blue Cross Blue Shield of Delaware</option>
<option value="Highmark Blue Cross Blue Shield of West Virginia">Highmark Blue Cross Blue Shield of West Virginia</option>
<option value="Highmark Blue Shield">Highmark Blue Shield</option>
<option value="HMO Colorado, Inc.">HMO Colorado, Inc.</option>
<option value="HMO Colorado, Inc. d/b/a HMO Nevada, Inc.">HMO Colorado, Inc. d/b/a HMO Nevada, Inc.</option>
<option value="HMO Louisiana, Inc.">HMO Louisiana, Inc.</option>
<option value="HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Missouri)">HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Missouri)</option>
<option value="HMO Partners, Inc.">HMO Partners, Inc.</option>
<option value="Horizon Blue Cross Blue Shield of New Jersey">Horizon Blue Cross Blue Shield of New Jersey</option>
<option value="Independence Administrators">Independence Administrators</option>
<option value="Independence Blue Cross">Independence Blue Cross</option>
<option value="Independence Hospital Indemnity Plan">Independence Hospital Indemnity Plan</option>
<option value="Keystone Health Plan Central, Inc. (KHPC)">Keystone Health Plan Central, Inc. (KHPC)</option>
<option value="Keystone Health Plan East">Keystone Health Plan East</option>
<option value="Keystone Health Plan West">Keystone Health Plan West</option>
<option value="Matthew Thornton Health Plan, Inc.">Matthew Thornton Health Plan, Inc.</option>
<option value="Mountain State Blue Cross Blue Shield">Mountain State Blue Cross Blue Shield</option>
<option value="Premera Blue Cross">Premera Blue Cross</option>
<option value="Premera Blue Cross Blue Shield">Premera Blue Cross Blue Shield</option>
<option value="Premera Blue Cross Blue Shield of Alaska">Premera Blue Cross Blue Shield of Alaska</option>
<option value="QCC Insurance Company">QCC Insurance Company</option>
<option value="Regence BlueCross BlueShield of Oregon">Regence BlueCross BlueShield of Oregon</option>
<option value="Regence BlueCross BlueShield of Utah">Regence BlueCross BlueShield of Utah</option>
<option value="Regence BlueShield">Regence BlueShield</option>
<option value="Regence BlueShield of Idaho">Regence BlueShield of Idaho</option>
<option value="Regence Group Administrators">Regence Group Administrators</option>
<option value="Regence Health Maintenance of Oregon">Regence Health Maintenance of Oregon</option>
<option value="Regence HMO Oregon">Regence HMO Oregon</option>
<option value="Regence Life and Health Insurance Company">Regence Life and Health Insurance Company</option>
<option value="Regence ValueCare">Regence ValueCare</option>
<option value="RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross and Blue Shield">RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Colorado)">Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Colorado)
</option>
<option value="Triple-S Management Corp.">Triple-S Management Corp.</option>
<option value="Triple-S Salud, Inc.">Triple-S Salud, Inc.</option>
<option value="USAble Mutual Insurance Company">USAble Mutual Insurance Company</option>
<option value="Wellmark BCBS of Iowa">Wellmark BCBS of Iowa</option>
<option value="Wellmark BCBS of South Dakota">Wellmark BCBS of South Dakota</option>
<option value="Wellmark Health Plan of Iowa">Wellmark Health Plan of Iowa</option>
<option value="Wellmark Synergy Health Plan">Wellmark Synergy Health Plan</option>
<option value="Wellmark Value Health Plan">Wellmark Value Health Plan</option>
<option value="Wisconsin Collaborative Insurance Company">Wisconsin Collaborative Insurance Company</option>
<option value="Other">Other</option>
</select><span class="k-picker-wrap k-state-default"><input title="" class="form-control k-input ui-autocomplete-input"
autocomplete="off"><a tabindex="-1" title="Show All Items" class="fa fa-chevron-down plan-dropdown-selector k-select"></a></span>
<div class="row health-plan-name-other" style="display: none;">
<div class="col-12">
<label for="both-health-plan-name-other-0" class="control-label">Other Health Plan Name</label>
<input id="both-health-plan-name-other-0" autocomplete="off" class="form-control" type="text" maxlength="200">
</div>
</div>
<span class="text-danger field-validation-valid" data-valmsg-for="Both.EmployeeHealthPlanDetails[0].Name" data-valmsg-replace="true"></span>
<input autocomplete="off" type="text" class="health-plan-name" maxlength="200" tabindex="-1" aria-labelledby="both-health-plan-name-select-0" data-val="true" data-val-maxlength="Plan name must be less than 200 characters."
data-val-maxlength-max="200" id="Both_EmployeeHealthPlanDetails_0__Name" name="Both.EmployeeHealthPlanDetails[0].Name" value="">
</div>
<div class="col-md-6">
<label class="control-label" for="Both_EmployeeHealthPlanDetails_0__GroupNumber">Group #</label>
<input autocomplete="off" type="text" class="form-control both-group-number" maxlength="100" id="Both_EmployeeHealthPlanDetails_0__GroupNumber" name="Both.EmployeeHealthPlanDetails[0].GroupNumber" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Both.EmployeeHealthPlanDetails[0].GroupNumber" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-md-12">
<label class="control-label required-field-label" for="Both_EmployeeHealthPlanDetails_0__EmployerName">Employer Name</label>
<input autocomplete="off" type="text" class="form-control both-employer-name" maxlength="100" data-val="true" data-val-required="This is required." id="Both_EmployeeHealthPlanDetails_0__EmployerName"
name="Both.EmployeeHealthPlanDetails[0].EmployerName" value="" aria-required="true">
<span class="text-danger field-validation-valid" data-valmsg-for="Both.EmployeeHealthPlanDetails[0].EmployerName" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-md-12">
<label class="control-label" for="Both_EmployeeHealthPlanDetails_0__EmployerMailingAddress">Employer Address</label>
<input autocomplete="off" type="text" class="form-control both-employer-address" maxlength="100" id="Both_EmployeeHealthPlanDetails_0__EmployerMailingAddress" name="Both.EmployeeHealthPlanDetails[0].EmployerMailingAddress"
value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Both.EmployeeHealthPlanDetails[0].EmployerMailingAddress" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-lg-12 col-xl-4">
<label class="control-label" for="Both_EmployeeHealthPlanDetails_0__SubscriberID">Subscriber or Member ID</label>
<input autocomplete="off" type="text" class="form-control both-subscriber-id" value="" maxlength="100" id="Both_EmployeeHealthPlanDetails_0__SubscriberID" name="Both.EmployeeHealthPlanDetails[0].SubscriberID">
<span class="text-danger field-validation-valid" data-valmsg-for="Both.EmployeeHealthPlanDetails[0].SubscriberID" data-valmsg-replace="true"></span>
</div>
<div class="col-lg-6 col-xl-4">
<label class="control-label start-date-label" for="Both_EmployeeHealthPlanDetails_0__CoverageStartDate">Coverage Start Date</label>
<span class="k-widget k-datepicker form-control coverageStartDate" style=""><span class="k-picker-wrap k-state-default"><input autocomplete="off" type="text" class="form-control coverageStartDate k-input" value=""
placeholder="MM/YYYY" id="Both_EmployeeHealthPlanDetails_0__CoverageStartDate" name="Both.EmployeeHealthPlanDetails[0].CoverageStartDate" data-role="datepicker" role="combobox" aria-expanded="false"
aria-owns="Both_EmployeeHealthPlanDetails_0__CoverageStartDate_dateview" aria-disabled="false" style="width: 100%;"><span class="k-icon k-i-warning"></span><span unselectable="on" class="k-select" aria-label="select"
role="button" aria-controls="Both_EmployeeHealthPlanDetails_0__CoverageStartDate_dateview"><span class="k-icon k-i-calendar"></span></span></span></span>
<span class="text-danger field-validation-valid" data-valmsg-for="Both.EmployeeHealthPlanDetails[0].CoverageStartDate" data-valmsg-replace="true"></span>
</div>
<div class="col-lg-6 col-xl-4">
<label class="control-label" for="Both_EmployeeHealthPlanDetails_0__CoverageEndDate">Coverage End Date</label>
<span class="k-widget k-datepicker form-control coverageEndDate" style=""><span class="k-picker-wrap k-state-default"><input autocomplete="off" type="text" class="form-control coverageEndDate k-input" value=""
placeholder="MM/YYYY" id="Both_EmployeeHealthPlanDetails_0__CoverageEndDate" name="Both.EmployeeHealthPlanDetails[0].CoverageEndDate" data-role="datepicker" role="combobox" aria-expanded="false"
aria-owns="Both_EmployeeHealthPlanDetails_0__CoverageEndDate_dateview" aria-disabled="false" style="width: 100%;"><span class="k-icon k-i-warning"></span><span unselectable="on" class="k-select" aria-label="select"
role="button" aria-controls="Both_EmployeeHealthPlanDetails_0__CoverageEndDate_dateview"><span class="k-icon k-i-calendar"></span></span></span></span>
<span class="text-danger field-validation-valid" data-valmsg-for="Both.EmployeeHealthPlanDetails[0].CoverageEndDate" data-valmsg-replace="true"></span>
</div>
</div>
</div>
<div id="both-individual-health-plan-wrapper-0" class="health-plan-wrapper" data-plan-type="individual">
<input type="hidden" id="Both.IndividualHealthPlanDetails.Index" name="Both.IndividualHealthPlanDetails.Index" value="0">
<div class="row sub-title">
<div class="col-sm-12">
<div class="row">
<div class="col-sm-8">
<div class="sub-num">2</div>
<h5 class="health-plan-heading">Individual Health Plan Entry</h5>
</div>
</div>
<hr>
</div>
</div>
<div class="row">
<div class="col-md-6 health-plan-name-form-group">
<label for="both-individual-health-plan-name-select-0" class="control-label">Health Plan Name</label>
<select id="both-individual-health-plan-name-select-0" class="health-plan-name-select" style="display: none;">
<option value=""></option>
<option value="Anthem Blue Cross Life and Health Insurance Company">Anthem Blue Cross Life and Health Insurance Company</option>
<option value="Anthem Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Kentucky)">Anthem Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Kentucky)</option>
<option value="Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Maine)">Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Maine)</option>
<option value="Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue Cross and Blue Shield (of New Hampshire)">Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue Cross and Blue Shield (of New Hampshire)
</option>
<option value="Anthem Health Plans of Virginia, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Virginia)">Anthem Health Plans of Virginia, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Virginia)</option>
<option value="Anthem Health Plans, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Connecticut)">Anthem Health Plans, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Connecticut)</option>
<option value="Anthem Insurance Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana)">Anthem Insurance Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana)</option>
<option value="Arkansas Blue Cross and Blue Shield">Arkansas Blue Cross and Blue Shield</option>
<option value="Blue Benefits Administrators">Blue Benefits Administrators</option>
<option value="Blue Care Network of Michigan">Blue Care Network of Michigan</option>
<option value="Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company">Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company</option>
<option value="Blue Cross & Blue Shield of Rhode Island">Blue Cross & Blue Shield of Rhode Island</option>
<option value="Blue Cross and Blue Shield of Alabama">Blue Cross and Blue Shield of Alabama</option>
<option value="Blue Cross and Blue Shield of Georgia, Inc.">Blue Cross and Blue Shield of Georgia, Inc.</option>
<option value="Blue Cross and Blue Shield of Illinois">Blue Cross and Blue Shield of Illinois</option>
<option value="Blue Cross and Blue Shield of Kansas">Blue Cross and Blue Shield of Kansas</option>
<option value="Blue Cross and Blue Shield of Kansas City">Blue Cross and Blue Shield of Kansas City</option>
<option value="Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.">Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.</option>
<option value="Blue Cross and Blue Shield of Massachusetts, Inc.">Blue Cross and Blue Shield of Massachusetts, Inc.</option>
<option value="Blue Cross and Blue Shield of Minnesota">Blue Cross and Blue Shield of Minnesota</option>
<option value="Blue Cross and Blue Shield of Montana">Blue Cross and Blue Shield of Montana</option>
<option value="Blue Cross and Blue Shield of New Mexico">Blue Cross and Blue Shield of New Mexico</option>
<option value="Blue Cross and Blue Shield of North Carolina">Blue Cross and Blue Shield of North Carolina</option>
<option value="Blue Cross and Blue Shield of Oklahoma">Blue Cross and Blue Shield of Oklahoma</option>
<option value="Blue Cross and Blue Shield of Texas">Blue Cross and Blue Shield of Texas</option>
<option value="Blue Cross and Blue Shield of Vermont">Blue Cross and Blue Shield of Vermont</option>
<option value="Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a Anthem Blue Cross and Blue Shield">Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Blue Cross Blue Shield of Delaware">Blue Cross Blue Shield of Delaware</option>
<option value="Blue Cross Blue Shield of Louisiana">Blue Cross Blue Shield of Louisiana</option>
<option value="Blue Cross Blue Shield of Massachusetts">Blue Cross Blue Shield of Massachusetts</option>
<option value="Blue Cross Blue Shield of Michigan">Blue Cross Blue Shield of Michigan</option>
<option value="Blue Cross Blue Shield of Nebraska">Blue Cross Blue Shield of Nebraska</option>
<option value="Blue Cross Blue Shield of North Dakota">Blue Cross Blue Shield of North Dakota</option>
<option value="Blue Cross Blue Shield of Northeastern Pennsylvania">Blue Cross Blue Shield of Northeastern Pennsylvania</option>
<option value="Blue Cross Blue Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield">Blue Cross Blue Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Blue Cross Blue Shield of Wyoming">Blue Cross Blue Shield of Wyoming</option>
<option value="Blue Cross of California d/b/a Anthem Blue Cross">Blue Cross of California d/b/a Anthem Blue Cross</option>
<option value="Blue Cross of Idaho">Blue Cross of Idaho</option>
<option value="Blue Plus">Blue Plus</option>
<option value="Blue Shield of California">Blue Shield of California</option>
<option value="Blue Shield of California Life & Health Insurance Company">Blue Shield of California Life & Health Insurance Company</option>
<option value="BlueAdvantage Administrators of Arkansas">BlueAdvantage Administrators of Arkansas</option>
<option value="BlueChoice HealthPlan of South Carolina">BlueChoice HealthPlan of South Carolina</option>
<option value="BlueCross BlueShield of Arizona">BlueCross BlueShield of Arizona</option>
<option value="BlueCross BlueShield of Florida, Inc.">BlueCross BlueShield of Florida, Inc.</option>
<option value="BlueCross BlueShield of South Carolina">BlueCross BlueShield of South Carolina</option>
<option value="BlueCross BlueShield of Tennessee">BlueCross BlueShield of Tennessee</option>
<option value="BlueCross BlueShield of Western New York">BlueCross BlueShield of Western New York</option>
<option value="BlueShield of Northeastern New York">BlueShield of Northeastern New York</option>
<option value="California Physicians’ Service dba Blue Shield of California">California Physicians’ Service dba Blue Shield of California</option>
<option value="Capital Advantage Assurance Company (CAAC)">Capital Advantage Assurance Company (CAAC)</option>
<option value="Capital Advantage Insurance Company (CAIC)">Capital Advantage Insurance Company (CAIC)</option>
<option value="Capital BlueCross">Capital BlueCross</option>
<option value="Capital Health Plan, Inc.">Capital Health Plan, Inc.</option>
<option value="CareFirst BlueChoice, Inc.">CareFirst BlueChoice, Inc.</option>
<option value="CareFirst BlueCross BlueShield DC/Montgomery County/Prince George’s County/Virginia">CareFirst BlueCross BlueShield DC/Montgomery County/Prince George’s County/Virginia</option>
<option value="CareFirst BlueCross BlueShield Maryland">CareFirst BlueCross BlueShield Maryland</option>
<option value="CareFirst of Maryland, Inc. (CFMI)">CareFirst of Maryland, Inc. (CFMI)</option>
<option value="CBA Blue (Vermont)">CBA Blue (Vermont)</option>
<option value="CFA LLC">CFA LLC</option>
<option value="Claim Management Services, Inc. d/b/a Anthem Blue Cross and Blue Shield">Claim Management Services, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Community Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Ohio)">Community Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Ohio)</option>
<option value="Compcare Health Services Insurance Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of Wisconsin)">Compcare Health Services Insurance Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of
Wisconsin)</option>
<option value="Empire HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield">Empire HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield</option>
<option value="Empire HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield">Empire HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield</option>
<option value="Excellus BlueCross BlueShield">Excellus BlueCross BlueShield</option>
<option value="First Priority Health">First Priority Health</option>
<option value="First Priority Life">First Priority Life</option>
<option value="Florida Blue">Florida Blue</option>
<option value="Florida Health Care Plan, Inc.">Florida Health Care Plan, Inc.</option>
<option value="Group Hospitalization and Medical Services, Inc. (GHMSI)">Group Hospitalization and Medical Services, Inc. (GHMSI)</option>
<option value="Hawaii Medical Service Association (HMSA)">Hawaii Medical Service Association (HMSA)</option>
<option value="Health Advantage">Health Advantage</option>
<option value="HealthKeepers, Inc.">HealthKeepers, Inc.</option>
<option value="Healthwise">Healthwise</option>
<option value="Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Missouri)">Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Missouri)</option>
<option value="Highmark Blue Cross Blue Shield">Highmark Blue Cross Blue Shield</option>
<option value="Highmark Blue Cross Blue Shield of Delaware">Highmark Blue Cross Blue Shield of Delaware</option>
<option value="Highmark Blue Cross Blue Shield of West Virginia">Highmark Blue Cross Blue Shield of West Virginia</option>
<option value="Highmark Blue Shield">Highmark Blue Shield</option>
<option value="HMO Colorado, Inc.">HMO Colorado, Inc.</option>
<option value="HMO Colorado, Inc. d/b/a HMO Nevada, Inc.">HMO Colorado, Inc. d/b/a HMO Nevada, Inc.</option>
<option value="HMO Louisiana, Inc.">HMO Louisiana, Inc.</option>
<option value="HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Missouri)">HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Missouri)</option>
<option value="HMO Partners, Inc.">HMO Partners, Inc.</option>
<option value="Horizon Blue Cross Blue Shield of New Jersey">Horizon Blue Cross Blue Shield of New Jersey</option>
<option value="Independence Administrators">Independence Administrators</option>
<option value="Independence Blue Cross">Independence Blue Cross</option>
<option value="Independence Hospital Indemnity Plan">Independence Hospital Indemnity Plan</option>
<option value="Keystone Health Plan Central, Inc. (KHPC)">Keystone Health Plan Central, Inc. (KHPC)</option>
<option value="Keystone Health Plan East">Keystone Health Plan East</option>
<option value="Keystone Health Plan West">Keystone Health Plan West</option>
<option value="Matthew Thornton Health Plan, Inc.">Matthew Thornton Health Plan, Inc.</option>
<option value="Mountain State Blue Cross Blue Shield">Mountain State Blue Cross Blue Shield</option>
<option value="Premera Blue Cross">Premera Blue Cross</option>
<option value="Premera Blue Cross Blue Shield">Premera Blue Cross Blue Shield</option>
<option value="Premera Blue Cross Blue Shield of Alaska">Premera Blue Cross Blue Shield of Alaska</option>
<option value="QCC Insurance Company">QCC Insurance Company</option>
<option value="Regence BlueCross BlueShield of Oregon">Regence BlueCross BlueShield of Oregon</option>
<option value="Regence BlueCross BlueShield of Utah">Regence BlueCross BlueShield of Utah</option>
<option value="Regence BlueShield">Regence BlueShield</option>
<option value="Regence BlueShield of Idaho">Regence BlueShield of Idaho</option>
<option value="Regence Group Administrators">Regence Group Administrators</option>
<option value="Regence Health Maintenance of Oregon">Regence Health Maintenance of Oregon</option>
<option value="Regence HMO Oregon">Regence HMO Oregon</option>
<option value="Regence Life and Health Insurance Company">Regence Life and Health Insurance Company</option>
<option value="Regence ValueCare">Regence ValueCare</option>
<option value="RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross and Blue Shield">RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Colorado)">Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Colorado)
</option>
<option value="Triple-S Management Corp.">Triple-S Management Corp.</option>
<option value="Triple-S Salud, Inc.">Triple-S Salud, Inc.</option>
<option value="USAble Mutual Insurance Company">USAble Mutual Insurance Company</option>
<option value="Wellmark BCBS of Iowa">Wellmark BCBS of Iowa</option>
<option value="Wellmark BCBS of South Dakota">Wellmark BCBS of South Dakota</option>
<option value="Wellmark Health Plan of Iowa">Wellmark Health Plan of Iowa</option>
<option value="Wellmark Synergy Health Plan">Wellmark Synergy Health Plan</option>
<option value="Wellmark Value Health Plan">Wellmark Value Health Plan</option>
<option value="Wisconsin Collaborative Insurance Company">Wisconsin Collaborative Insurance Company</option>
<option value="Other">Other</option>
</select><span class="k-picker-wrap k-state-default"><input title="" class="form-control k-input ui-autocomplete-input"
autocomplete="off"><a tabindex="-1" title="Show All Items" class="fa fa-chevron-down plan-dropdown-selector k-select"></a></span>
<div class="row health-plan-name-other" style="display: none;">
<div class="col-12">
<label for="both-individual-health-plan-name-other-0" class="control-label">Other Health Plan Name</label>
<input id="both-individual-health-plan-name-other-0" autocomplete="off" class="form-control" type="text" maxlength="200">
</div>
</div>
<span class="text-danger field-validation-valid" data-valmsg-for="Both.IndividualHealthPlanDetails[0].Name" data-valmsg-replace="true"></span>
<input autocomplete="off" type="text" class="health-plan-name" maxlength="200" tabindex="-1" aria-labelledby="both-individual-health-plan-name-select-0" data-val="true"
data-val-maxlength="Plan name must be less than 200 characters." data-val-maxlength-max="200" id="Both_IndividualHealthPlanDetails_0__Name" name="Both.IndividualHealthPlanDetails[0].Name" value="">
</div>
<div class="col-md-6">
<label class="control-label" for="Both_IndividualHealthPlanDetails_0__GroupNumber">Group #</label>
<input autocomplete="off" type="text" class="form-control both-group-number" maxlength="100" id="Both_IndividualHealthPlanDetails_0__GroupNumber" name="Both.IndividualHealthPlanDetails[0].GroupNumber" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Both.IndividualHealthPlanDetails[0].GroupNumber" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-lg-12 col-xl-4">
<label class="control-label subscriber-id-label" for="Both_IndividualHealthPlanDetails_0__SubscriberID">Subscriber ID</label>
<input autocomplete="off" type="text" class="form-control both-subscriber-id" maxlength="100" id="Both_IndividualHealthPlanDetails_0__SubscriberID" name="Both.IndividualHealthPlanDetails[0].SubscriberID" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Both.IndividualHealthPlanDetails[0].SubscriberID" data-valmsg-replace="true"></span>
</div>
<div class="col-lg-6 col-xl-4">
<label class="control-label start-date-label" for="Both_IndividualHealthPlanDetails_0__CoverageStartDate">Coverage Start Date</label>
<span class="k-widget k-datepicker form-control coverageStartDate" style=""><span class="k-picker-wrap k-state-default"><input autocomplete="off" type="text" class="form-control coverageStartDate k-input" value=""
placeholder="MM/YYYY" id="Both_IndividualHealthPlanDetails_0__CoverageStartDate" name="Both.IndividualHealthPlanDetails[0].CoverageStartDate" data-role="datepicker" role="combobox" aria-expanded="false"
aria-owns="Both_IndividualHealthPlanDetails_0__CoverageStartDate_dateview" aria-disabled="false" style="width: 100%;"><span class="k-icon k-i-warning"></span><span unselectable="on" class="k-select" aria-label="select"
role="button" aria-controls="Both_IndividualHealthPlanDetails_0__CoverageStartDate_dateview"><span class="k-icon k-i-calendar"></span></span></span></span>
<span class="text-danger field-validation-valid" data-valmsg-for="Both.IndividualHealthPlanDetails[0].CoverageStartDate" data-valmsg-replace="true"></span>
</div>
<div class="col-lg-6 col-xl-4">
<label class="control-label" for="Both_IndividualHealthPlanDetails_0__CoverageEndDate">Coverage End Date</label>
<span class="k-widget k-datepicker form-control coverageEndDate" style=""><span class="k-picker-wrap k-state-default"><input autocomplete="off" type="text" class="form-control coverageEndDate k-input" value=""
placeholder="MM/YYYY" id="Both_IndividualHealthPlanDetails_0__CoverageEndDate" name="Both.IndividualHealthPlanDetails[0].CoverageEndDate" data-role="datepicker" role="combobox" aria-expanded="false"
aria-owns="Both_IndividualHealthPlanDetails_0__CoverageEndDate_dateview" aria-disabled="false" style="width: 100%;"><span class="k-icon k-i-warning"></span><span unselectable="on" class="k-select" aria-label="select"
role="button" aria-controls="Both_IndividualHealthPlanDetails_0__CoverageEndDate_dateview"><span class="k-icon k-i-calendar"></span></span></span></span>
<span class="text-danger field-validation-valid" data-valmsg-for="Both.IndividualHealthPlanDetails[0].CoverageEndDate" data-valmsg-replace="true"></span>
</div>
</div>
</div>
</div>
<hr>
<div class="row">
<div class="col-sm-12">
<div class="alert alert-danger" role="alert" id="groupNrRequiredErrMsg" style="display: none">
<i class="fa fa-exclamation-circle"></i> Group # field is required.
</div>
<div class="alert alert-danger" role="alert" id="coverageStartDateRequiredErrMsg" style="display: none">
<i class="fa fa-exclamation-circle"></i> LocKey_CoverageStartDateRequiredErrMsgRequiredErrMsg
</div>
<div class="alert alert-danger" role="alert" id="coverageEndDateRequiredErrMsg" style="display: none">
<i class="fa fa-exclamation-circle"></i> LocKey_CoverageEndDateRequiredErrMsgRequiredErrMsg
</div>
</div>
</div>
<div class="row mt-3">
<div class="col-lg-6">
<button type="button" id="add-both-employee-healthplan-btn" class="btn btn-primary-outline btn-block"><i class="fa fa-plus-square"></i> Add Employee Health Plan</button>
</div>
<div class="col-lg-6">
<button type="button" id="add-individual-healthplan-btn" class="btn btn-primary-outline btn-block"><i class="fa fa-plus-square"></i> Add Individual Health Plan</button>
</div>
</div>
</div>
</div>
<div id="add-both-employee-healthplan-template" class="hidden">
<div id="both-employee-health-plan-wrapper-{count}" class="health-plan-wrapper-hidden" data-plan-type="employee">
<div class="row sub-title">
<div class="col-sm-12">
<div class="row">
<div class="col-sm-8">
<div class="sub-num"></div>
<h5 class="health-plan-heading">Health Plan Entry</h5>
</div>
<div class="col-sm-4">
<button type="button" data-service-count="{count}" class="remove-both-employee-healthplan-btn btn btn-link float-right"><i class="fa fa-trash"></i> Delete Entry</button>
</div>
</div>
<hr>
</div>
</div>
<div class="row">
<div class="col-md-6 health-plan-name-form-group">
<label for="both-health-plan-name-select-{count}" class="control-label">Health Plan Name</label>
<select id="both-health-plan-name-select-{count}" class="health-plan-name-select">
<option value=""></option>
<option value="Anthem Blue Cross Life and Health Insurance Company">Anthem Blue Cross Life and Health Insurance Company</option>
<option value="Anthem Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Kentucky)">Anthem Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Kentucky)</option>
<option value="Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Maine)">Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Maine)</option>
<option value="Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue Cross and Blue Shield (of New Hampshire)">Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue Cross and Blue Shield (of New Hampshire)</option>
<option value="Anthem Health Plans of Virginia, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Virginia)">Anthem Health Plans of Virginia, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Virginia)</option>
<option value="Anthem Health Plans, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Connecticut)">Anthem Health Plans, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Connecticut)</option>
<option value="Anthem Insurance Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana)">Anthem Insurance Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana)</option>
<option value="Arkansas Blue Cross and Blue Shield">Arkansas Blue Cross and Blue Shield</option>
<option value="Blue Benefits Administrators">Blue Benefits Administrators</option>
<option value="Blue Care Network of Michigan">Blue Care Network of Michigan</option>
<option value="Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company">Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company</option>
<option value="Blue Cross & Blue Shield of Rhode Island">Blue Cross & Blue Shield of Rhode Island</option>
<option value="Blue Cross and Blue Shield of Alabama">Blue Cross and Blue Shield of Alabama</option>
<option value="Blue Cross and Blue Shield of Georgia, Inc.">Blue Cross and Blue Shield of Georgia, Inc.</option>
<option value="Blue Cross and Blue Shield of Illinois">Blue Cross and Blue Shield of Illinois</option>
<option value="Blue Cross and Blue Shield of Kansas">Blue Cross and Blue Shield of Kansas</option>
<option value="Blue Cross and Blue Shield of Kansas City">Blue Cross and Blue Shield of Kansas City</option>
<option value="Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.">Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.</option>
<option value="Blue Cross and Blue Shield of Massachusetts, Inc.">Blue Cross and Blue Shield of Massachusetts, Inc.</option>
<option value="Blue Cross and Blue Shield of Minnesota">Blue Cross and Blue Shield of Minnesota</option>
<option value="Blue Cross and Blue Shield of Montana">Blue Cross and Blue Shield of Montana</option>
<option value="Blue Cross and Blue Shield of New Mexico">Blue Cross and Blue Shield of New Mexico</option>
<option value="Blue Cross and Blue Shield of North Carolina">Blue Cross and Blue Shield of North Carolina</option>
<option value="Blue Cross and Blue Shield of Oklahoma">Blue Cross and Blue Shield of Oklahoma</option>
<option value="Blue Cross and Blue Shield of Texas">Blue Cross and Blue Shield of Texas</option>
<option value="Blue Cross and Blue Shield of Vermont">Blue Cross and Blue Shield of Vermont</option>
<option value="Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a Anthem Blue Cross and Blue Shield">Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Blue Cross Blue Shield of Delaware">Blue Cross Blue Shield of Delaware</option>
<option value="Blue Cross Blue Shield of Louisiana">Blue Cross Blue Shield of Louisiana</option>
<option value="Blue Cross Blue Shield of Massachusetts">Blue Cross Blue Shield of Massachusetts</option>
<option value="Blue Cross Blue Shield of Michigan">Blue Cross Blue Shield of Michigan</option>
<option value="Blue Cross Blue Shield of Nebraska">Blue Cross Blue Shield of Nebraska</option>
<option value="Blue Cross Blue Shield of North Dakota">Blue Cross Blue Shield of North Dakota</option>
<option value="Blue Cross Blue Shield of Northeastern Pennsylvania">Blue Cross Blue Shield of Northeastern Pennsylvania</option>
<option value="Blue Cross Blue Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield">Blue Cross Blue Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Blue Cross Blue Shield of Wyoming">Blue Cross Blue Shield of Wyoming</option>
<option value="Blue Cross of California d/b/a Anthem Blue Cross">Blue Cross of California d/b/a Anthem Blue Cross</option>
<option value="Blue Cross of Idaho">Blue Cross of Idaho</option>
<option value="Blue Plus">Blue Plus</option>
<option value="Blue Shield of California">Blue Shield of California</option>
<option value="Blue Shield of California Life & Health Insurance Company">Blue Shield of California Life & Health Insurance Company</option>
<option value="BlueAdvantage Administrators of Arkansas">BlueAdvantage Administrators of Arkansas</option>
<option value="BlueChoice HealthPlan of South Carolina">BlueChoice HealthPlan of South Carolina</option>
<option value="BlueCross BlueShield of Arizona">BlueCross BlueShield of Arizona</option>
<option value="BlueCross BlueShield of Florida, Inc.">BlueCross BlueShield of Florida, Inc.</option>
<option value="BlueCross BlueShield of South Carolina">BlueCross BlueShield of South Carolina</option>
<option value="BlueCross BlueShield of Tennessee">BlueCross BlueShield of Tennessee</option>
<option value="BlueCross BlueShield of Western New York">BlueCross BlueShield of Western New York</option>
<option value="BlueShield of Northeastern New York">BlueShield of Northeastern New York</option>
<option value="California Physicians’ Service dba Blue Shield of California">California Physicians’ Service dba Blue Shield of California</option>
<option value="Capital Advantage Assurance Company (CAAC)">Capital Advantage Assurance Company (CAAC)</option>
<option value="Capital Advantage Insurance Company (CAIC)">Capital Advantage Insurance Company (CAIC)</option>
<option value="Capital BlueCross">Capital BlueCross</option>
<option value="Capital Health Plan, Inc.">Capital Health Plan, Inc.</option>
<option value="CareFirst BlueChoice, Inc.">CareFirst BlueChoice, Inc.</option>
<option value="CareFirst BlueCross BlueShield DC/Montgomery County/Prince George’s County/Virginia">CareFirst BlueCross BlueShield DC/Montgomery County/Prince George’s County/Virginia</option>
<option value="CareFirst BlueCross BlueShield Maryland">CareFirst BlueCross BlueShield Maryland</option>
<option value="CareFirst of Maryland, Inc. (CFMI)">CareFirst of Maryland, Inc. (CFMI)</option>
<option value="CBA Blue (Vermont)">CBA Blue (Vermont)</option>
<option value="CFA LLC">CFA LLC</option>
<option value="Claim Management Services, Inc. d/b/a Anthem Blue Cross and Blue Shield">Claim Management Services, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Community Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Ohio)">Community Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Ohio)</option>
<option value="Compcare Health Services Insurance Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of Wisconsin)">Compcare Health Services Insurance Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of
Wisconsin)</option>
<option value="Empire HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield">Empire HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield</option>
<option value="Empire HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield">Empire HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield</option>
<option value="Excellus BlueCross BlueShield">Excellus BlueCross BlueShield</option>
<option value="First Priority Health">First Priority Health</option>
<option value="First Priority Life">First Priority Life</option>
<option value="Florida Blue">Florida Blue</option>
<option value="Florida Health Care Plan, Inc.">Florida Health Care Plan, Inc.</option>
<option value="Group Hospitalization and Medical Services, Inc. (GHMSI)">Group Hospitalization and Medical Services, Inc. (GHMSI)</option>
<option value="Hawaii Medical Service Association (HMSA)">Hawaii Medical Service Association (HMSA)</option>
<option value="Health Advantage">Health Advantage</option>
<option value="HealthKeepers, Inc.">HealthKeepers, Inc.</option>
<option value="Healthwise">Healthwise</option>
<option value="Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Missouri)">Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Missouri)</option>
<option value="Highmark Blue Cross Blue Shield">Highmark Blue Cross Blue Shield</option>
<option value="Highmark Blue Cross Blue Shield of Delaware">Highmark Blue Cross Blue Shield of Delaware</option>
<option value="Highmark Blue Cross Blue Shield of West Virginia">Highmark Blue Cross Blue Shield of West Virginia</option>
<option value="Highmark Blue Shield">Highmark Blue Shield</option>
<option value="HMO Colorado, Inc.">HMO Colorado, Inc.</option>
<option value="HMO Colorado, Inc. d/b/a HMO Nevada, Inc.">HMO Colorado, Inc. d/b/a HMO Nevada, Inc.</option>
<option value="HMO Louisiana, Inc.">HMO Louisiana, Inc.</option>
<option value="HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Missouri)">HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Missouri)</option>
<option value="HMO Partners, Inc.">HMO Partners, Inc.</option>
<option value="Horizon Blue Cross Blue Shield of New Jersey">Horizon Blue Cross Blue Shield of New Jersey</option>
<option value="Independence Administrators">Independence Administrators</option>
<option value="Independence Blue Cross">Independence Blue Cross</option>
<option value="Independence Hospital Indemnity Plan">Independence Hospital Indemnity Plan</option>
<option value="Keystone Health Plan Central, Inc. (KHPC)">Keystone Health Plan Central, Inc. (KHPC)</option>
<option value="Keystone Health Plan East">Keystone Health Plan East</option>
<option value="Keystone Health Plan West">Keystone Health Plan West</option>
<option value="Matthew Thornton Health Plan, Inc.">Matthew Thornton Health Plan, Inc.</option>
<option value="Mountain State Blue Cross Blue Shield">Mountain State Blue Cross Blue Shield</option>
<option value="Premera Blue Cross">Premera Blue Cross</option>
<option value="Premera Blue Cross Blue Shield">Premera Blue Cross Blue Shield</option>
<option value="Premera Blue Cross Blue Shield of Alaska">Premera Blue Cross Blue Shield of Alaska</option>
<option value="QCC Insurance Company">QCC Insurance Company</option>
<option value="Regence BlueCross BlueShield of Oregon">Regence BlueCross BlueShield of Oregon</option>
<option value="Regence BlueCross BlueShield of Utah">Regence BlueCross BlueShield of Utah</option>
<option value="Regence BlueShield">Regence BlueShield</option>
<option value="Regence BlueShield of Idaho">Regence BlueShield of Idaho</option>
<option value="Regence Group Administrators">Regence Group Administrators</option>
<option value="Regence Health Maintenance of Oregon">Regence Health Maintenance of Oregon</option>
<option value="Regence HMO Oregon">Regence HMO Oregon</option>
<option value="Regence Life and Health Insurance Company">Regence Life and Health Insurance Company</option>
<option value="Regence ValueCare">Regence ValueCare</option>
<option value="RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross and Blue Shield">RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Colorado)">Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Colorado)
</option>
<option value="Triple-S Management Corp.">Triple-S Management Corp.</option>
<option value="Triple-S Salud, Inc.">Triple-S Salud, Inc.</option>
<option value="USAble Mutual Insurance Company">USAble Mutual Insurance Company</option>
<option value="Wellmark BCBS of Iowa">Wellmark BCBS of Iowa</option>
<option value="Wellmark BCBS of South Dakota">Wellmark BCBS of South Dakota</option>
<option value="Wellmark Health Plan of Iowa">Wellmark Health Plan of Iowa</option>
<option value="Wellmark Synergy Health Plan">Wellmark Synergy Health Plan</option>
<option value="Wellmark Value Health Plan">Wellmark Value Health Plan</option>
<option value="Wisconsin Collaborative Insurance Company">Wisconsin Collaborative Insurance Company</option>
<option value="Other">Other</option>
</select>
<div class="row health-plan-name-other" style="display: none;">
<div class="col-12">
<label for="both-health-plan-name-other-{count}" class="control-label">Other Health Plan Name</label>
<input id="both-health-plan-name-other-{count}" autocomplete="off" class="form-control" type="text" maxlength="200">
</div>
</div>
<span data-valmsg-for="Both.EmployeeHealthPlanDetails[{count}].Name" class="text-danger" data-valmsg-replace="true"></span>
<input autocomplete="off" type="text" name="Both.EmployeeHealthPlanDetails[{count}].Name" class="health-plan-name" maxlength="200" tabindex="-1" aria-labelledby="both-health-plan-name-select-{count}">
</div>
<div class="col-md-6">
<label class="control-label">Group #</label>
<input autocomplete="off" type="text" name="Both.EmployeeHealthPlanDetails[{count}].GroupNumber" class="form-control both-group-number" maxlength="100">
<span data-valmsg-for="Both.EmployeeHealthPlanDetails[{count}].GroupNumber" class="text-danger" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-md-12">
<label class="control-label required-field-label">Employer Name</label>
<input autocomplete="off" type="text" name="Both.EmployeeHealthPlanDetails[{count}].EmployerName" class="form-control both-employer-name" maxlength="100">
<span data-valmsg-for="Both.EmployeeHealthPlanDetails[{count}].EmployerName" data-valmsg-replace="true" class="text-danger"></span>
</div>
</div>
<div class="row">
<div class="col-md-12">
<label class="control-label">Employer Address</label>
<input autocomplete="off" type="text" name="Both.EmployeeHealthPlanDetails[{count}].EmployerMailingAddress" class="form-control both-employer-address" maxlength="100">
<span data-valmsg-for="Both.EmployeeHealthPlanDetails[{count}].EmployerMailingAddress" data-valmsg-replace="true" class="text-danger"></span>
</div>
</div>
<div class="row">
<div class="col-lg-12 col-xl-4">
<label class="control-label">Subscriber or Member ID</label>
<input autocomplete="off" type="text" name="Both.EmployeeHealthPlanDetails[{count}].SubscriberID" class="form-control both-subscriber-id" value="" maxlength="100">
<span data-valmsg-for="Both.EmployeeHealthPlanDetails[{count}].SubscriberID" data-valmsg-replace="true" class="text-danger"></span>
</div>
<div class="col-lg-6 col-xl-4">
<label class="control-label start-date-label">Coverage Start Date</label>
<input autocomplete="off" type="date" name="Both.EmployeeHealthPlanDetails[{count}].CoverageStartDate" class="form-control coverageStartDate" value="" placeholder="MM/YYYY">
<span data-valmsg-for="Both.EmployeeHealthPlanDetails[{count}].CoverageStartDate" data-valmsg-replace="true" class="text-danger"></span>
</div>
<div class="col-lg-6 col-xl-4">
<label class="control-label">Coverage End Date</label>
<input autocomplete="off" type="date" name="Both.EmployeeHealthPlanDetails[{count}].CoverageEndDate" class="form-control coverageEndDate" value="" placeholder="MM/YYYY">
<span data-valmsg-for="Both.EmployeeHealthPlanDetails[{count}].CoverageEndDate" data-valmsg-replace="true" class="text-danger"></span>
</div>
</div>
</div>
</div>
<div id="add-individual-healthplan-template" class="hidden">
<div id="both-individual-health-plan-wrapper-{count}" class="health-plan-wrapper-hidden" data-plan-type="individual">
<div class="row sub-title">
<div class="col-sm-12">
<div class="row">
<div class="col-sm-8">
<div class="sub-num"></div>
<h5 class="health-plan-heading">Health Plan Entry</h5>
</div>
<div class="col-sm-4">
<button type="button" data-service-count="{count}" class="remove-individual-healthplan-btn btn btn-link float-right"><i class="fa fa-trash"></i> Delete Entry</button>
</div>
</div>
<hr>
</div>
</div>
<div class="row">
<div class="col-md-6 health-plan-name-form-group">
<label for="both-individual-health-plan-name-select-{count}" class="control-label">Health Plan Name</label>
<select id="both-individual-health-plan-name-select-{count}" class="health-plan-name-select">
<option value=""></option>
<option value="Anthem Blue Cross Life and Health Insurance Company">Anthem Blue Cross Life and Health Insurance Company</option>
<option value="Anthem Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Kentucky)">Anthem Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Kentucky)</option>
<option value="Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Maine)">Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Maine)</option>
<option value="Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue Cross and Blue Shield (of New Hampshire)">Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue Cross and Blue Shield (of New Hampshire)</option>
<option value="Anthem Health Plans of Virginia, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Virginia)">Anthem Health Plans of Virginia, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Virginia)</option>
<option value="Anthem Health Plans, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Connecticut)">Anthem Health Plans, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Connecticut)</option>
<option value="Anthem Insurance Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana)">Anthem Insurance Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana)</option>
<option value="Arkansas Blue Cross and Blue Shield">Arkansas Blue Cross and Blue Shield</option>
<option value="Blue Benefits Administrators">Blue Benefits Administrators</option>
<option value="Blue Care Network of Michigan">Blue Care Network of Michigan</option>
<option value="Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company">Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company</option>
<option value="Blue Cross & Blue Shield of Rhode Island">Blue Cross & Blue Shield of Rhode Island</option>
<option value="Blue Cross and Blue Shield of Alabama">Blue Cross and Blue Shield of Alabama</option>
<option value="Blue Cross and Blue Shield of Georgia, Inc.">Blue Cross and Blue Shield of Georgia, Inc.</option>
<option value="Blue Cross and Blue Shield of Illinois">Blue Cross and Blue Shield of Illinois</option>
<option value="Blue Cross and Blue Shield of Kansas">Blue Cross and Blue Shield of Kansas</option>
<option value="Blue Cross and Blue Shield of Kansas City">Blue Cross and Blue Shield of Kansas City</option>
<option value="Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.">Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.</option>
<option value="Blue Cross and Blue Shield of Massachusetts, Inc.">Blue Cross and Blue Shield of Massachusetts, Inc.</option>
<option value="Blue Cross and Blue Shield of Minnesota">Blue Cross and Blue Shield of Minnesota</option>
<option value="Blue Cross and Blue Shield of Montana">Blue Cross and Blue Shield of Montana</option>
<option value="Blue Cross and Blue Shield of New Mexico">Blue Cross and Blue Shield of New Mexico</option>
<option value="Blue Cross and Blue Shield of North Carolina">Blue Cross and Blue Shield of North Carolina</option>
<option value="Blue Cross and Blue Shield of Oklahoma">Blue Cross and Blue Shield of Oklahoma</option>
<option value="Blue Cross and Blue Shield of Texas">Blue Cross and Blue Shield of Texas</option>
<option value="Blue Cross and Blue Shield of Vermont">Blue Cross and Blue Shield of Vermont</option>
<option value="Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a Anthem Blue Cross and Blue Shield">Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Blue Cross Blue Shield of Delaware">Blue Cross Blue Shield of Delaware</option>
<option value="Blue Cross Blue Shield of Louisiana">Blue Cross Blue Shield of Louisiana</option>
<option value="Blue Cross Blue Shield of Massachusetts">Blue Cross Blue Shield of Massachusetts</option>
<option value="Blue Cross Blue Shield of Michigan">Blue Cross Blue Shield of Michigan</option>
<option value="Blue Cross Blue Shield of Nebraska">Blue Cross Blue Shield of Nebraska</option>
<option value="Blue Cross Blue Shield of North Dakota">Blue Cross Blue Shield of North Dakota</option>
<option value="Blue Cross Blue Shield of Northeastern Pennsylvania">Blue Cross Blue Shield of Northeastern Pennsylvania</option>
<option value="Blue Cross Blue Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield">Blue Cross Blue Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Blue Cross Blue Shield of Wyoming">Blue Cross Blue Shield of Wyoming</option>
<option value="Blue Cross of California d/b/a Anthem Blue Cross">Blue Cross of California d/b/a Anthem Blue Cross</option>
<option value="Blue Cross of Idaho">Blue Cross of Idaho</option>
<option value="Blue Plus">Blue Plus</option>
<option value="Blue Shield of California">Blue Shield of California</option>
<option value="Blue Shield of California Life & Health Insurance Company">Blue Shield of California Life & Health Insurance Company</option>
<option value="BlueAdvantage Administrators of Arkansas">BlueAdvantage Administrators of Arkansas</option>
<option value="BlueChoice HealthPlan of South Carolina">BlueChoice HealthPlan of South Carolina</option>
<option value="BlueCross BlueShield of Arizona">BlueCross BlueShield of Arizona</option>
<option value="BlueCross BlueShield of Florida, Inc.">BlueCross BlueShield of Florida, Inc.</option>
<option value="BlueCross BlueShield of South Carolina">BlueCross BlueShield of South Carolina</option>
<option value="BlueCross BlueShield of Tennessee">BlueCross BlueShield of Tennessee</option>
<option value="BlueCross BlueShield of Western New York">BlueCross BlueShield of Western New York</option>
<option value="BlueShield of Northeastern New York">BlueShield of Northeastern New York</option>
<option value="California Physicians’ Service dba Blue Shield of California">California Physicians’ Service dba Blue Shield of California</option>
<option value="Capital Advantage Assurance Company (CAAC)">Capital Advantage Assurance Company (CAAC)</option>
<option value="Capital Advantage Insurance Company (CAIC)">Capital Advantage Insurance Company (CAIC)</option>
<option value="Capital BlueCross">Capital BlueCross</option>
<option value="Capital Health Plan, Inc.">Capital Health Plan, Inc.</option>
<option value="CareFirst BlueChoice, Inc.">CareFirst BlueChoice, Inc.</option>
<option value="CareFirst BlueCross BlueShield DC/Montgomery County/Prince George’s County/Virginia">CareFirst BlueCross BlueShield DC/Montgomery County/Prince George’s County/Virginia</option>
<option value="CareFirst BlueCross BlueShield Maryland">CareFirst BlueCross BlueShield Maryland</option>
<option value="CareFirst of Maryland, Inc. (CFMI)">CareFirst of Maryland, Inc. (CFMI)</option>
<option value="CBA Blue (Vermont)">CBA Blue (Vermont)</option>
<option value="CFA LLC">CFA LLC</option>
<option value="Claim Management Services, Inc. d/b/a Anthem Blue Cross and Blue Shield">Claim Management Services, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Community Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Ohio)">Community Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Ohio)</option>
<option value="Compcare Health Services Insurance Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of Wisconsin)">Compcare Health Services Insurance Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of
Wisconsin)</option>
<option value="Empire HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield">Empire HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield</option>
<option value="Empire HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield">Empire HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield</option>
<option value="Excellus BlueCross BlueShield">Excellus BlueCross BlueShield</option>
<option value="First Priority Health">First Priority Health</option>
<option value="First Priority Life">First Priority Life</option>
<option value="Florida Blue">Florida Blue</option>
<option value="Florida Health Care Plan, Inc.">Florida Health Care Plan, Inc.</option>
<option value="Group Hospitalization and Medical Services, Inc. (GHMSI)">Group Hospitalization and Medical Services, Inc. (GHMSI)</option>
<option value="Hawaii Medical Service Association (HMSA)">Hawaii Medical Service Association (HMSA)</option>
<option value="Health Advantage">Health Advantage</option>
<option value="HealthKeepers, Inc.">HealthKeepers, Inc.</option>
<option value="Healthwise">Healthwise</option>
<option value="Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Missouri)">Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and Blue Shield (of Missouri)</option>
<option value="Highmark Blue Cross Blue Shield">Highmark Blue Cross Blue Shield</option>
<option value="Highmark Blue Cross Blue Shield of Delaware">Highmark Blue Cross Blue Shield of Delaware</option>
<option value="Highmark Blue Cross Blue Shield of West Virginia">Highmark Blue Cross Blue Shield of West Virginia</option>
<option value="Highmark Blue Shield">Highmark Blue Shield</option>
<option value="HMO Colorado, Inc.">HMO Colorado, Inc.</option>
<option value="HMO Colorado, Inc. d/b/a HMO Nevada, Inc.">HMO Colorado, Inc. d/b/a HMO Nevada, Inc.</option>
<option value="HMO Louisiana, Inc.">HMO Louisiana, Inc.</option>
<option value="HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Missouri)">HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Missouri)</option>
<option value="HMO Partners, Inc.">HMO Partners, Inc.</option>
<option value="Horizon Blue Cross Blue Shield of New Jersey">Horizon Blue Cross Blue Shield of New Jersey</option>
<option value="Independence Administrators">Independence Administrators</option>
<option value="Independence Blue Cross">Independence Blue Cross</option>
<option value="Independence Hospital Indemnity Plan">Independence Hospital Indemnity Plan</option>
<option value="Keystone Health Plan Central, Inc. (KHPC)">Keystone Health Plan Central, Inc. (KHPC)</option>
<option value="Keystone Health Plan East">Keystone Health Plan East</option>
<option value="Keystone Health Plan West">Keystone Health Plan West</option>
<option value="Matthew Thornton Health Plan, Inc.">Matthew Thornton Health Plan, Inc.</option>
<option value="Mountain State Blue Cross Blue Shield">Mountain State Blue Cross Blue Shield</option>
<option value="Premera Blue Cross">Premera Blue Cross</option>
<option value="Premera Blue Cross Blue Shield">Premera Blue Cross Blue Shield</option>
<option value="Premera Blue Cross Blue Shield of Alaska">Premera Blue Cross Blue Shield of Alaska</option>
<option value="QCC Insurance Company">QCC Insurance Company</option>
<option value="Regence BlueCross BlueShield of Oregon">Regence BlueCross BlueShield of Oregon</option>
<option value="Regence BlueCross BlueShield of Utah">Regence BlueCross BlueShield of Utah</option>
<option value="Regence BlueShield">Regence BlueShield</option>
<option value="Regence BlueShield of Idaho">Regence BlueShield of Idaho</option>
<option value="Regence Group Administrators">Regence Group Administrators</option>
<option value="Regence Health Maintenance of Oregon">Regence Health Maintenance of Oregon</option>
<option value="Regence HMO Oregon">Regence HMO Oregon</option>
<option value="Regence Life and Health Insurance Company">Regence Life and Health Insurance Company</option>
<option value="Regence ValueCare">Regence ValueCare</option>
<option value="RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross and Blue Shield">RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross and Blue Shield</option>
<option value="Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Colorado)">Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Colorado)
</option>
<option value="Triple-S Management Corp.">Triple-S Management Corp.</option>
<option value="Triple-S Salud, Inc.">Triple-S Salud, Inc.</option>
<option value="USAble Mutual Insurance Company">USAble Mutual Insurance Company</option>
<option value="Wellmark BCBS of Iowa">Wellmark BCBS of Iowa</option>
<option value="Wellmark BCBS of South Dakota">Wellmark BCBS of South Dakota</option>
<option value="Wellmark Health Plan of Iowa">Wellmark Health Plan of Iowa</option>
<option value="Wellmark Synergy Health Plan">Wellmark Synergy Health Plan</option>
<option value="Wellmark Value Health Plan">Wellmark Value Health Plan</option>
<option value="Wisconsin Collaborative Insurance Company">Wisconsin Collaborative Insurance Company</option>
<option value="Other">Other</option>
</select>
<div class="row health-plan-name-other" style="display: none;">
<div class="col-12">
<label for="both-individual-health-plan-name-other-{count}" class="control-label">Other Health Plan Name</label>
<input id="both-individual-health-plan-name-other-{count}" autocomplete="off" class="form-control" type="text" maxlength="200">
</div>
</div>
<span data-valmsg-for="Both.IndividualHealthPlanDetails[{count}].Name" class="text-danger" data-valmsg-replace="true"></span>
<input autocomplete="off" type="text" name="Both.IndividualHealthPlanDetails[{count}].Name" class="health-plan-name" maxlength="200" tabindex="-1" aria-labelledby="both-individual-health-plan-name-select-{count}">
</div>
<div class="col-md-6">
<label class="control-label">Group #</label>
<input autocomplete="off" type="text" name="Both.IndividualHealthPlanDetails[{count}].GroupNumber" class="form-control both-group-number" maxlength="100">
<span data-valmsg-for="Both.IndividualHealthPlanDetails[{count}].GroupNumber" class="text-danger" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-lg-12 col-xl-4">
<label class="control-label subscriber-id-label">Subscriber ID</label>
<input autocomplete="off" type="text" name="Both.IndividualHealthPlanDetails[{count}].SubscriberID" class="form-control both-subscriber-id" maxlength="100">
<span data-valmsg-for="Both.IndividualHealthPlanDetails[{count}].SubscriberID" class="text-danger" data-valmsg-replace="true"></span>
</div>
<div class="col-lg-6 col-xl-4">
<label class="control-label start-date-label">Coverage Start Date</label>
<input autocomplete="off" type="date" name="Both.IndividualHealthPlanDetails[{count}].CoverageStartDate" class="form-control coverageStartDate" value="" placeholder="MM/YYYY">
<span data-valmsg-for="Both.IndividualHealthPlanDetails[{count}].CoverageStartDate" class="text-danger" data-valmsg-replace="true"></span>
</div>
<div class="col-lg-6 col-xl-4">
<label class="control-label">Coverage End Date</label>
<input autocomplete="off" type="date" name="Both.IndividualHealthPlanDetails[{count}].CoverageEndDate" class="form-control coverageEndDate" value="" placeholder="MM/YYYY">
<span data-valmsg-for="Both.IndividualHealthPlanDetails[{count}].CoverageEndDate" class="text-danger" data-valmsg-replace="true"></span>
</div>
</div>
</div>
</div>
</section>
<!-- SECTION 23. -->
<section id="option4section43" class="datalosswarning-on allocation-of-premiums-section">
<div class="allocation-of-premiums-introduction question-group">
<div class="row title-icon">
<div class="col-sm-12">
<h2>
<i class="fal fa-file-contract"></i> Allocation of Premiums
</h2>
</div>
</div>
<div class="row title-desc">
<div class="col-sm-12">
<p> The Settlement provides that payments will be based, in part, on premiums paid for BCBS health insurance or administrative services plans during the relevant periods between February 2008 and October 2020 for fully insured plans,
and between September 2015 and October 2020 for administrative services plans. </p>
<p>The Settlement further provides default formulas for the Claims Administrator to use when determining what percentage of the premium was paid by an employer/entity and what percentage was contributed by its employees/members.</p>
<p> If you accept the <a data-html="true" data-toggle="popover" title="" data-content="100% of premiums for employees who do not file claims are allocated to the claiming employer. When an employee does claim, their premium share is determined through the default formulas, which provide that employees with single coverage are allocated 15% (for fully-insured health insurance) or 18% (for administrative plans) of the total premium paid on their behalf by their employer, and employees with family coverage are allocated 34% (for fully-insured health insurance) or 25% (for administrative plans), with the remainder allocated to the employer. For a full discussion of how these formulas will be used in calculating claims, please refer to the <a href="https://www.bcbssettlement.com/admin/services/connectedapps.cms.extensions/1.0.0.0/asset?id=4a81c01d-f915-4cc4-bec8-3df1d1dda5c5&languageId=1033&inline=true" target="_blank">Plan of Distribution</a> on the Settlement Website." data-trigger="manual" tabindex="0" data-original-title="<i class="fa fa-info-circle"></i> Default Option">
Default option
<i class="fa fa-info-circle"></i>
</a> , you are <b>NOT</b> required to provide any additional data or evidence in support of your claim at this time. If another claimant’s filing affects your claim, you will be provided with an opportunity to respond at a later
date. </p>
<p> If you proceed with the <a data-html="true" data-toggle="popover" title="" data-content="Selecting the alternative option requires that you provide the percentage contribution you believe you contributed for each year that you were enrolled in a BCBS health insurance or administrative services plan. If you choose to apply for an alternative contribution percentage you must supply documentation with this claim form supporting the percentage you claim to have contributed. For a full discussion of how these formulas will be used in calculating claims, please refer to the <a href="https://www.bcbssettlement.com/admin/services/connectedapps.cms.extensions/1.0.0.0/asset?id=4a81c01d-f915-4cc4-bec8-3df1d1dda5c5&languageId=1033&inline=true" target="_blank">Plan of Distribution</a> on the Settlement Website." data-trigger="manual" tabindex="0" data-original-title="<i class="fa fa-info-circle"></i> Alternative Option">
Alternative option
<i class="fa fa-info-circle"></i>
</a> , you must also provide data or evidence to support the alternative contribution percentages you provide. If you select this option, for any time period for which supporting data or evidence is not provided, the Default Option
will be applied. </p>
</div>
</div>
</div>
<div class="allocation-of-premiums-decision question-group">
<input autocomplete="off" type="hidden" value="true" data-val="true" data-val-required="This is required." id="Both_AllocationOfPremiums_HasAcceptedDefaultAllocationOption"
name="Both.AllocationOfPremiums.HasAcceptedDefaultAllocationOption">
<div class="allocation-options row">
<div class="col-lg-6">
<div class="allocation-option selected-allocation-option" data-accept-default-allocation="true" tabindex="0">
<div class="wrapper">
<h3>Accept the Default Option</h3>
<div class="icon"><i class="fal fa-check-circle"></i></div>
</div>
</div>
</div>
<div class="col-lg-6">
<div class="allocation-option" data-accept-default-allocation="false" data-toggle="modal" data-target="#both-flow .alternative-contribution-warning" tabindex="0">
<div class="wrapper">
<h3>Apply for an Alternative Contribution %</h3>
<div class="icon"><i class="fal fa-file-alt"></i></div>
</div>
</div>
</div>
</div>
</div>
<div class="allocation-of-premiums-alternative" style="display:none;">
<div class="row">
<div class="col-md-12">
<div class="default-option-cta">
<div class="row">
<div class="col-md-12">
<div class="wrapper">
<div class="icon">
<div class="circle">
<img src="https://www.bcbssettlement.com/shk/ocf/images/stop-sign.png" alt="Stop Sign">
</div>
</div>
<div class="text">
<p>
<span class="double-underline"><span class="lines"></span><b>STOP:</b></span>
<b>If you want to use the DEFAULT OPTION,</b>
<span class="double-underline"><span class="lines"></span><b>DO NOT</b></span>
<b>FILL OUT THIS SECTION. Instead, click</b>
<a class="allocation-option" data-accept-default-allocation="true" data-dismiss="modal">
<u>HERE</u>.
</a>
</p>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row sub-title">
<div class="col-sm-12">
<div class="sub-num">1</div>
<h5>Alternative Option</h5>
<hr>
</div>
</div>
<div class="row title-desc">
<div class="col-sm-12">
<p> Please state the percentage contribution you believe you contributed for each year that you were enrolled in a BCBS health insurance or administrative services plan. </p>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="allocation-of-premiums-contributions">
<div class="row">
<div class="col-6 col-sm-3">
<label id="both-allocation-year-header" class="required-field-label">Plan Year</label>
</div>
<div class="col-6 col-sm-5">
<label id="both-allocation-contribution-header" class="required-field-label">Contribution</label>
</div>
</div>
<hr>
<div id="both-allocation-of-premiums-contributions-wrapper-0" class="allocation-of-premiums-contributions-wrapper">
<input autocomplete="off" type="hidden" id="Both.AllocationOfPremiums.AllocationOfPremiumsContributions.Index" name="Both.AllocationOfPremiums.AllocationOfPremiumsContributions.Index" value="0">
<div class="row mb-2">
<div class="col-6 col-sm-3">
<select class="year form-control" aria-labelledby="both-allocation-year-header" data-val="true" data-val-range="Invalid Year." data-val-range-max="2020" data-val-range-min="2008"
id="Both_AllocationOfPremiums_AllocationOfPremiumsContributions_0__Year" name="Both.AllocationOfPremiums.AllocationOfPremiumsContributions[0].Year" aria-required="true">
<option value=""></option>
<option>2008</option>
<option>2009</option>
<option>2010</option>
<option>2011</option>
<option>2012</option>
<option>2013</option>
<option>2014</option>
<option>2015</option>
<option>2016</option>
<option>2017</option>
<option>2018</option>
<option>2019</option>
<option>2020</option>
</select><span class="text-danger text-wrap field-validation-valid" data-valmsg-for="Both.AllocationOfPremiums.AllocationOfPremiumsContributions[0].Year" data-valmsg-replace="true"></span>
</div>
<div class="col-6 col-sm-5">
<input autocomplete="off" style="display:inline; width:80%;" type="text" class="allocation-contribution-percent percent form-control" aria-labelledby="both-allocation-contribution-header" data-val="true"
data-val-number="The field ContributionPercent must be a number." id="Both_AllocationOfPremiums_AllocationOfPremiumsContributions_0__ContributionPercent"
name="Both.AllocationOfPremiums.AllocationOfPremiumsContributions[0].ContributionPercent" value="" aria-required="true">
<div style="display:inline;">%</div>
<span class="text-danger text-wrap field-validation-valid" data-valmsg-for="Both.AllocationOfPremiums.AllocationOfPremiumsContributions[0].ContributionPercent" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-4"></div>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<button type="button" class="add-allocations-of-premiums-year btn btn-primary-outline"><i class="fa fa-plus"></i>ADD ANOTHER YEAR</button>
</div>
</div>
</div>
</div>
</div>
<div class="row sub-title">
<div class="col-sm-12">
<div class="sub-num">2</div>
<h5 id="both-flow-alternative-allocation-supporting-docs-header" class="alternative-allocation-supporting-docs-header">Upload Supporting Documentation</h5>
<hr>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<p> If you choose to apply for an alternative contribution percentage you must supply documentation with this claim form supporting the percentage you claim to have contributed. If you do not submit supporting documentation the
Default contribution rates will be applied to your claim. </p>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="alert alert-secondary">
<label><input type="checkbox" class="mr-2" data-val="true" data-val-required="You must upload documents now or check the box if you will provide documents later."
id="Both_AllocationOfPremiums_UploadAlternativeAllocationOfPremiumsDocsLater" name="Both.AllocationOfPremiums.UploadAlternativeAllocationOfPremiumsDocsLater" value="true"> Check this box if you want to upload your documents
later. </label>
</div>
<span class="text-danger field-validation-valid" data-valmsg-for="Both.AllocationOfPremiums.UploadAlternativeAllocationOfPremiumsDocsLater" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="supporting-documents-allocation-of-premiums">
<div class="row mb-2">
<div class="col-sm-12">
<p class="text-grey">Supported files include: .jpg, .jpeg, .pdf, .png, .tif, and .tiff. Maximum upload size is 10MB</p>
</div>
</div>
<div id="both-allocation-of-premiums-file-inputs-0" class="allocation-of-premiums-file-inputs">
<div class="row">
<div class="col-sm-8">
<input type="file" accept=".jpg, .png, .jpeg, .pdf, .tif, .tiff" style="overflow: hidden" class="form-control allocation-of-premiums-input-file" id="both-allocation-of-premiums-doc_0" name="both.AllocationOfPremiumsDoc_0"
aria-labelledby="both-flow-alternative-allocation-supporting-docs-header">
<span data-valmsg-for="both.AllocationOfPremiumsDoc_0" class="text-danger" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-4">
<a class="clearFileInput"><i class="fa fa-trash"></i> DELETE FILE</a>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<button type="button" class="add-row-allocation-of-premiums-doc btn btn-primary-outline"><i class="fa fa-plus"></i>ADD ANOTHER FILE</button>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="alternative-contribution-warning modal fade" tabindex="-1" role="dialog" aria-labelledby="alternative-contribution-warning-title">
<div class="modal-dialog" role="document">
<div class="modal-content">
<div class="modal-header">
<h3 class="modal-title" id="alternative-contribution-warning-title">
<i class="fal fa-info-circle"></i> Alternative Contribution
</h3>
<button type="button" class="close" data-dismiss="modal" aria-label="Close">
<span aria-hidden="true">×</span>
</button>
</div>
<div class="modal-body">
<p>If you choose to apply for an alternative contribution percentage, you must supply documentation with this claim form supporting the percentage you claim to have contributed. If you do not provide additional documentation, the
Default Option will be applied to your claim.</p>
<p>Selection of the Alternative Option does not ensure a contribution percentage higher than or equal to the Default Option. Your percentage will be dependent on a process that includes a review of all materials submitted pertaining
to your premium.</p>
<p>Are you sure you want to apply for an alternative contribution percentage?</p>
</div>
<div class="modal-footer">
<div class="row mb-2">
<div class="col-sm-12">
<button type="button" class="btn btn-primary-outline allocation-option" data-accept-default-allocation="false" data-dismiss="modal">
<i class="far fa-file-alt"></i>
<span> Continue with alternative option </span>
</button>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<button type="button" class="btn btn-primary allocation-option" data-accept-default-allocation="true" data-dismiss="modal">
<i class="far fa-check-circle"></i>
<span> Switch to the default option </span>
</button>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="add-contribution-template hidden">
<div id="both-allocation-of-premiums-contributions-wrapper-{count}" class="allocation-of-premiums-contributions-wrapper-hidden">
<div class="row mb-2">
<div class="col-6 col-sm-3">
<select name="Both.AllocationOfPremiums.AllocationOfPremiumsContributions[{count}].Year" class="year form-control" aria-labelledby="allocation-year-header">
<option value=""></option>
<option>2008</option>
<option>2009</option>
<option>2010</option>
<option>2011</option>
<option>2012</option>
<option>2013</option>
<option>2014</option>
<option>2015</option>
<option>2016</option>
<option>2017</option>
<option>2018</option>
<option>2019</option>
<option>2020</option>
</select><span data-valmsg-for="Both.AllocationOfPremiums.AllocationOfPremiumsContributions[{count}].Year" class="text-danger text-wrap" data-valmsg-replace="true"></span>
</div>
<div class="col-6 col-sm-5">
<input style="display:inline; width:80%;" autocomplete="off" type="text" name="Both.AllocationOfPremiums.AllocationOfPremiumsContributions[{count}].ContributionPercent" class="allocation-contribution-percent percent form-control"
aria-labelledby="both-allocation-contribution-header" data-val="true" data-val-number="The field ContributionPercent must be a number.">
<div style="display:inline;">%</div>
<span data-valmsg-for="Both.AllocationOfPremiums.AllocationOfPremiumsContributions[{count}].ContributionPercent" class="text-danger text-wrap" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-4 text-left text-sm-right">
<button type="button" data-service-count="{count}" class="btn btn-link remove-allocations-of-premiums-year">
<i class="fa fa-trash"></i> Delete Entry </button>
</div>
</div>
</div>
</div>
<div class="add-documents-template hidden">
<div id="both-allocation-of-premiums-file-inputs-{count}" class="allocation-of-premiums-file-inputs-hidden">
<div class="row mb-2">
<div class="col-sm-8">
<input type="file" accept=".jpg, .png, .jpeg, .pdf, .tif, .tiff" style="overflow: hidden;" class="form-control allocation-of-premiums-input-file" id="both-allocation-of-premiums-doc_{count}"
name="both.AllocationOfPremiumsDoc_{count}" @*="" data-val="true" data-val-shkfilesize="Invalid file size" *@="" aria-labelledby="both-flow-alternative-allocation-supporting-docs-header">
<span data-valmsg-for="both.AllocationOfPremiumsDoc_{count}" class="text-danger" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-4">
<button type="button" data-service-count="{count}" class="btn btn-link remove-allocations-of-premiums-input-file">
<i class="fa fa-trash"></i> DELETE FILE </button>
</div>
</div>
</div>
</div>
</section>
<!-- SECTION 24. -->
<section id="option4section44" class="datalosswarning-on">
<div class="question-group">
<div class="row title-icon">
<div class="col-sm-12">
<h2>
<i class="fal fa-money-check-alt"></i> Payment Election
</h2>
</div>
</div>
<div class="row title-desc">
<div class="col-sm-12">
<p> Please let us know how you would like to receive your settlement payment if your claim is deemed valid.</p>
<p> Final determinations of claim amounts will not be made until after processing by the Claims Administrator is complete. Claims will not be paid if the value is equal to or less than $5.00.</p>
<p> Claimants who submit valid, approved claims shall receive a pro-rata percentage of the Net Settlement Fund allocated to their type of coverage (fully-insured or self-funded) based upon their estimated proportion of the cumulative
total of premiums and/or administrative fees paid by all claimants.</p>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="payment-election-wrapper">
<div class="row mb-2">
<div class="col-sm-6">
<label class="required-field-label" for="Both_Shared_SelectedPaymentOption">Payment Option</label>
<select class="form-control" data-val="true" data-val-required="This is required." id="Both_Shared_SelectedPaymentOption" name="Both.Shared.SelectedPaymentOption">
<option value="" selected="">Please Select</option>
<option value="Venmo">Venmo</option>
<option value="PayPal">PayPal</option>
<option value="Pre-paid Card">Pre-paid Card</option>
<option value="Check">Check</option>
</select><span class="text-danger field-validation-valid" data-valmsg-for="Both.Shared.SelectedPaymentOption" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-6 payment-option-user" style="display:none">
<label for="Both_Shared_PaymentOptionUsername">Venmo Username</label>
<input autocomplete="off" type="text" class="form-control" aria-labelledby="Both_Shared_PaymentOptionUsername" data-val="true" data-val-requiredif="This is required." data-val-requiredif-comp="isequalto"
data-val-requiredif-other="SelectedPaymentOption" data-val-requiredif-value="Venmo" id="Both_Shared_PaymentOptionUsername" name="Both.Shared.PaymentOptionUsername" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Both.Shared.PaymentOptionUsername" data-valmsg-replace="true"></span>
</div>
<div class="col-sm-6 payment-option-email" style="display:none">
<label for="Both_Shared_PayPalEmail">PayPal Email</label>
<input autocomplete="off" type="text" class="form-control" aria-labelledby="Both_Shared_PayPalEmail" data-val="true" data-val-email="Invalid Email Format." data-val-regex="Invalid Email Format."
data-val-regex-pattern="^[\w!#$%&'*+\-/=?\^_`{|}~]+(\.[\w!#$%&'*+\-/=?\^_`{|}~]+)*@((([\-\w]+\.)+[a-zA-Z0-9\-]{2,})|(([0-9]{1,3}\.){3}[0-9]{1,3}))$" data-val-requiredif="This is required."
data-val-requiredif-comp="isequalto" data-val-requiredif-other="SelectedPaymentOption" data-val-requiredif-value="PayPal" id="Both_Shared_PayPalEmail" name="Both.Shared.PayPalEmail" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Both.Shared.PayPalEmail" data-valmsg-replace="true"></span>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<!-- SECTION 25. -->
<section id="option4section45" class="datalosswarning-on review-section">
<div class="summary-section confirmation-section" id="contact-text" style="display: none">
<div class="row title-icon">
<div class="col-sm-12">
<h2>
<i class="fal fa-check-circle"></i> Confirmation
</h2>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<p>Your claim form has been submitted successfully. Please keep the Claim Number below for your records.</p>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="alert alert-secondary">
<strong>Claim Number:</strong>
<span class="confirmation-claim-number"></span>
</div>
</div>
</div>
<div class="ConfirmationPageUploadedDocuments" style="display: none;">
<div class="row">
<div class="col-md-12">
<h4>Supporting Documentation</h4>
</div>
</div>
</div>
</div>
<button type="button" style="display:none;" class="btn btn-lg btn-primary float-right print-claim">
<span>Print a Copy of Your Claim</span> <i class="fad fa-print"></i>
</button>
<!-- Header -->
<div class="summary-section please-review">
<div class="row title-icon">
<div class="col-sm-12">
<h2>
<i class="fal fa-file-contract"></i> Review
</h2>
</div>
</div>
<div class="row title-desc mb-0">
<div class="col-sm-12"> Please review your claim information below. If you need to make any edits to your claim, you may go back to a page by clicking that section of the progress bar or clicking the Back button at the bottom of the
page. If everything is correct, complete the <a href="#both-review-signature-header">Signature</a> section at the bottom of the page and click the Submit button. </div>
</div>
</div>
<!-- Contact Info -->
<div class="summary-section">
<div class="row title-icon">
<div class="col-sm-12">
<h2 id="both-review-contact-info-header" class="review-contact-info-header">
<i class="fal fa-address-card"></i> Subscriber Information
</h2>
</div>
</div>
<div class="row sub-title">
<div class="col-sm-12">
<h5>Mailing Address</h5>
<hr>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="control-label" for="Both_Shared_MailingStreetLine1_Summary">Street Line 1</label>
<p class="form-control-static" id="Both_Shared_MailingStreetLine1_Summary"></p>
</div>
<div class="col-sm-6">
<label class="control-label" for="Both_Shared_MailingStreetLine2_Summary">Street Line 2</label>
<p class="form-control-static" id="Both_Shared_MailingStreetLine2_Summary"></p>
</div>
</div>
<div class="row mb-2">
<div class="col-sm-6">
<label class="control-label" for="Both_Shared_MailingCity_Summary">City</label>
<p class="form-control-static" id="Both_Shared_MailingCity_Summary"></p>
</div>
<div class="col-sm-3 review-field-us">
<label class="control-label" for="Both_Shared_MailingSubDivision_Summary">State</label>
<p class="form-control-static" id="Both_Shared_MailingSubDivision_Summary"></p>
</div>
<div class="col-sm-3 review-field-us">
<label class="control-label" for="Both_Shared_MailingPostalCode_Summary">Zip</label>
<p class="form-control-static" id="Both_Shared_MailingPostalCode_Summary"></p>
</div>
<div class="col-sm-3 review-field-non-us">
<label class="control-label" for="Both_Shared_MailingSubDivisionNonUS_Summary">Province</label>
<p class="form-control-static" id="Both_Shared_MailingSubDivisionNonUS_Summary"></p>
</div>
<div class="col-sm-3 review-field-non-us">
<label class="control-label" for="Both_Shared_MailingPostalCodeNonUS_Summary">Postal Code</label>
<p class="form-control-static" id="Both_Shared_MailingPostalCodeNonUS_Summary"></p>
</div>
<div class="col-sm-3 review-field-non-us">
<label class="control-label" for="Both_Shared_MailingCountry_Summary">Country</label>
<p class="form-control-static" id="Both_Shared_MailingCountry_Summary"></p>
</div>
</div>
<div class="row sub-title">
<div class="col-sm-12">
<h5>Subscriber Name</h5>
<hr>
</div>
</div>
<div class="row">
<div class="col-sm-3">
<label class="control-label" for="Both_Shared_FirstName_Summary">First Name</label>
<p class="form-control-static" id="Both_Shared_FirstName_Summary"></p>
</div>
<div class="col-sm-3">
<label class="control-label" for="Both_Shared_MiddleInitial_Summary">Middle Initial</label>
<p class="form-control-static" id="Both_Shared_MiddleInitial_Summary"></p>
</div>
<div class="col-sm-6">
<label class="control-label" for="Both_Shared_LastName_Summary">Last Name</label>
<p class="form-control-static" id="Both_Shared_LastName_Summary"></p>
</div>
</div>
<div class="row sub-title">
<div class="col-sm-12">
<h5>Phone Number</h5>
<hr>
</div>
</div>
<div class="row mb-2">
<div class="col-sm-12 review-field-us">
<label class="control-label" for="Both_Shared_PhoneNumber_Summary">Phone</label>
<p class="form-control-static" id="Both_Shared_PhoneNumber_Summary"></p>
</div>
<div class="col-sm-12 review-field-non-us">
<label class="control-label" for="Both_Shared_PhoneNumberNonUS_Summary">Phone</label>
<p class="form-control-static" id="Both_Shared_PhoneNumberNonUS_Summary"></p>
</div>
</div>
<div class="row sub-title">
<div class="col-sm-12">
<h5>Email Address</h5>
<hr>
</div>
</div>
<div class="row mb-2">
<div class="col-sm-12">
<label class="control-label" for="Both_Shared_EmailAddress_Summary">Email</label>
<p class="form-control-static" id="Both_Shared_EmailAddress_Summary"></p>
</div>
</div>
</div>
<!-- Health Plan -->
<div class="summary-section">
<div class="row title-icon">
<div class="col-sm-12">
<h2 id="both-review-healthplan-header" class="review-healthplan-header">
<i class="fal fa-stethoscope"></i> Health Plan Details
</h2>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="review-healthplans"></div>
</div>
</div>
</div>
<!-- Allocations of Premiums -->
<div class="summary-section">
<div class="row title-icon">
<div class="col-sm-12">
<h2 id="both-review-allocationofpremiums-header" class="review-allocationofpremiums-header">
<i class="fal fa-file-contract"></i> Allocation of Premiums
</h2>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div class="review-allocation-alternative-selected allocation-option" style="display:none;">
<div class="wrapper">
<h3>Alternative Contribution % Selected</h3>
<div class="icon"><i class="fal fa-file-alt"></i></div>
</div>
</div>
<div class="review-allocation-default-selected allocation-option" style="display:none;">
<div class="wrapper">
<h3>Default Option Selected</h3>
<div class="icon"><i class="fal fa-check-circle"></i></div>
</div>
</div>
</div>
</div>
<div class="review-alternative-option-section" style="display:none;">
<div class="row sub-title">
<div class="col-md-12">
<h5>Alternative Option</h5>
<hr>
</div>
</div>
<div class="review-contributions mb-3">
<div class="row">
<div class="col-6 col-sm-3 font-weight-bold">Plan Year</div>
<div class="col-6 col-sm-3 font-weight-bold">Contribution</div>
</div>
<hr>
<div class="review-alternative-options"></div>
</div>
<div class="row sub-title">
<div class="col-md-12">
<h5>Upload Supporting Documentation</h5>
<hr>
</div>
</div>
<div class="row">
<div class="col-md-12 review-supporting-document-summary"></div>
<div class="col-md-12 review-supporting-document-none-selected"></div>
</div>
</div>
<div style="display: none" class="upload-in-progress mt-4">
<div class="row">
<div class="col-md-12 text-center upload-in-progress-title"> Please Wait For Upload </div>
</div>
<div class="row">
<div class="col-md-12 review-supporting-document-list">
</div>
</div>
<div class="failed-upload-block" style="display: none">
<div class="row">
<div class="col-md-12">
<b>Upload Failed For Files</b>
</div>
</div>
<div class="row">
<div class="col-md-12 failed-file-list" style="color:red;"></div>
</div>
</div>
</div>
</div>
<!-- Payment Election -->
<div class="summary-section">
<div class="row title-icon">
<div class="col-sm-12">
<h2 id="both-review-paymentelection-header" class="review-paymentelection-header">
<i class="fal fa-money-check-alt"></i> Payment Election
</h2>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="control-label" for="Both_Shared_SelectedPaymentOption">Payment Option</label>
<p class="form-control-static" id="Both_Shared_SelectedPaymentOption_Summary"></p>
</div>
<div class="col-sm-6 payment-option-user">
<label class="control-label" for="Both_Shared_PaymentOptionUsername">Venmo Username</label>
<p class="form-control-static" id="Both_Shared_PaymentOptionUsername_Summary"></p>
</div>
<div class="col-sm-6 payment-option-email">
<label class="control-label" for="Both_Shared_PayPalEmail">PayPal Email</label>
<p class="form-control-static" id="Both_Shared_PayPalEmail_Summary"></p>
</div>
</div>
</div>
<!-- Signature -->
<div class="summary-section">
<div class="row title-icon">
<div class="col-sm-12">
<h2 id="both-review-signature-header" class="review-signature-header">
<i class="fal fa-file-signature"></i> Signature
</h2>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="alert alert-secondary">
<div class="row">
<div class="col-sm-1" style="max-width: 20px;">
<input type="checkbox" data-val="true" data-val-required="This is required." id="Both_Shared_AffirmSignature" name="Both.Shared.AffirmSignature" value="true" aria-required="true">
</div>
<div class="col-sm-11">
<label class="control-label required-field-label" for="Both_Shared_AffirmSignature">By checking this box, I affirm under the laws of the United States and the laws of my State of residence that the information supplied in this
Claim Form by the undersigned is true and correct to the best of my recollection, and that this form was executed on the date set forth below.</label>
</div>
</div>
</div>
<span class="text-danger field-validation-valid" data-valmsg-for="Both.Shared.AffirmSignature" data-valmsg-replace="true"></span>
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<div class="col-sm-12">
<div class="alert alert-secondary">
<div class="row">
<div class="col-sm-1" style="max-width: 20px;">
<input type="checkbox" data-val="true" data-val-required="This is required." id="Both_Shared_AffirmMayProvideAdditionalInfo" name="Both.Shared.AffirmMayProvideAdditionalInfo" value="true" aria-required="true">
</div>
<div class="col-sm-11">
<label class="control-label required-field-label" for="Both_Shared_AffirmMayProvideAdditionalInfo">By checking this box, I understand that I may be asked to provide supplemental information to the Claims Administrator and/or
Settlement Administrator before my claim will be considered complete and valid.</label>
</div>
</div>
</div>
<span class="text-danger field-validation-valid" data-valmsg-for="Both.Shared.AffirmMayProvideAdditionalInfo" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-lg-8">
<label class="control-label required-field-label" for="Both_Shared_Signature">Type your name in the box below to electronically sign your claim</label>
<input autocomplete="off" type="text" class="form-control" maxlength="200" data-val="true" data-val-required="Please type your name above." id="Both_Shared_Signature" name="Both.Shared.Signature" value="">
<span class="text-danger field-validation-valid" data-valmsg-for="Both.Shared.Signature" data-valmsg-replace="true"></span>
</div>
<div class="col-lg-4">
<label class="control-label signature-date-label" for="Both_Shared_SignatureDate">Date</label>
<input class="form-control" readonly="" type="text" id="Both_Shared_SignatureDate" name="Both.Shared.SignatureDate" value="10/11/2021">
<span class="text-danger field-validation-valid" data-valmsg-for="Both.Shared.SignatureDate" data-valmsg-replace="true"></span>
</div>
</div>
</div>
<div id="review-health-plan-template" class="hidden">
<div class="review-healthplan-row-hidden">
<div class="row sub-title">
<div class="col-sm-12">
<h5 class="review-healthplan-title"></h5>
<hr>
</div>
</div>
<div class="row">
<div class="col-sm-3">
<label class="control-label">Health Plan Name</label>
<p class="form-control-static review-health-plan-name"></p>
</div>
<div class="col-sm-3">
<label class="control-label">Group #</label>
<p class="form-control-static review-health-plan-group-number"></p>
</div>
<div class="col-sm-3">
<label class="control-label">Coverage Start Date</label>
<p class="form-control-static review-health-plan-coverage-start-date"></p>
</div>
<div class="col-sm-3">
<label class="control-label">Coverage End Date</label>
<p class="form-control-static review-health-plan-coverage-end-date"></p>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<label class="control-label">Employer Name</label>
<p class="form-control-static review-health-plan-employer-name"></p>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<label class="control-label">Employer Address</label>
<p class="form-control-static review-health-plan-employer-address"></p>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<label class="control-label">Subscriber or Member ID</label>
<p class="form-control-static review-health-plan-subscriber-id"></p>
</div>
</div>
</div>
</div>
<div id="review-individual-health-plan-template" class="hidden">
<div class="review-healthplan-row-hidden">
<div class="row sub-title">
<div class="col-sm-12">
<h5 class="review-healthplan-title"></h5>
<hr>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="control-label">Health Plan Name</label>
<p class="form-control-static review-health-plan-name"></p>
</div>
<div class="col-sm-6">
<label class="control-label">Group #</label>
<p class="form-control-static review-health-plan-group-number"></p>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="control-label">Subscriber ID</label>
<p class="form-control-static review-health-plan-subscriber-id"></p>
</div>
<div class="col-sm-3">
<label class="control-label">Coverage Start Date</label>
<p class="form-control-static review-health-plan-coverage-start-date"></p>
</div>
<div class="col-sm-3">
<label class="control-label">Coverage End Date</label>
<p class="form-control-static review-health-plan-coverage-end-date"></p>
</div>
</div>
</div>
</div>
<div class="review-alternative-options-template hidden">
<div class="review-allocation-row-hidden">
<div class="row">
<div class="col-6 col-sm-3">
<p class="form-control-static review-alternative-option-year"></p>
</div>
<div class="col-6 col-sm-3">
<p class="form-control-static review-alternative-option-contribution" style="display:inline;"></p>
<p style="display:inline;">%</p>
</div>
</div>
</div>
</div>
<div class="claim-submit-error-text" style="display: none">
<div class="row response-section">
<div class="col-sm-12">
<div class="alert alert-danger">
<h4 class="mb-2">
<i class="fa fa-exclamation-triangle mr-2 claim-submit-error-icon-warning"></i>
<i class="fad fa-spinner-third fa-spin mr-2 claim-submit-error-icon-working" style="display: none;"></i> Error
</h4>
<div class="claim-submit-error-subheader">Your Claim Form Has Not Been Submitted</div>
<div class="claim-submit-error-text-message"></div>
</div>
</div>
</div>
</div>
</section>
</div>
<!-- #endregion -->
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</form>Text Content
BLUE CROSS BLUE SHIELD ONLINE CLAIM FORM
ESPAÑOL
Return Home
ONLINE CLAIM FORM
Please enter the Unique ID contained in the email or on the postcard notice that
you received and click Login.
Unique ID LOGIN
DON'T HAVE A UNIQUE ID?
File a claim here
ARE YOU FILING FOR A BUSINESS OR ARE YOU FILING FOR YOURSELF ?
BUSINESS
MYSELF
WERE YOU ENROLLED THROUGH YOUR EMPLOYER OR OTHER ENTITY , OR DID YOU BUY
INSURANCE DIRECTLY FROM A BCBS COMPANY, OR DO BOTH?
ENROLLED THROUGH EMPLOYER
PURCHASED MYSELF
BOTH
×
You have selected a new filing option. Any data you entered for the previous
selection will not be saved. Do you want to continue?
Cancel Yes
1
Business Information
2
Health Plan Details
3
Allocation of Premiums
4
Payment Election
5
Review & Signature
1
Subscriber Information
2
Health Plan Details
3
Allocation of Premiums
4
Payment Election
5
Review & Signature
1
Subscriber Information
2
Health Plan Details
3
Payment Election
4
Review & Signature
1
Subscriber Information
2
Health Plan Details
3
Allocation of Premiums
4
Payment Election
5
Review & Signature
BUSINESS INFORMATION
Please provide the following information:
1
FULL NAME OF COMPANY
--------------------------------------------------------------------------------
Company
2
PRIMARY HEADQUARTERS MAILING ADDRESS
--------------------------------------------------------------------------------
Street Line 1
Street Line 2
City
State Alabama Alaska American Samoa Arizona Arkansas California Colorado
Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho
Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts
Michigan Minnesota Mississippi Missouri Northern Mariana Islands Montana
Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina
North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South
Carolina South Dakota Tennessee Texas Utah Vermont Virginia U.S. Virgin Islands
Washington West Virginia Wisconsin Wyoming AA AP AE
Province
Zip
Postal Code
Country Andorra Afghanistan Antigua and Barbuda Albania Armenia Angola Argentina
Austria Australia Azerbaijan Bosnia and Herzegovina Barbados Bangladesh Belgium
Burkina Faso Bulgaria Bahrain Burundi Benin Brunei Darussalam
Bolivia(Plurinational State of) Brazil Bahamas Bhutan Botswana Belarus Belize
Canada Central African Republic Congo Côte d'Ivoire Cape Verde Chile Cameroon
China Colombia Costa Rica Cuba Comoros Cyprus Czech Republic Germany Djibouti
Democratic Republic of the Congo Denmark Dominica Dominican Republic Algeria
Ecuador Estonia Egypt Eritrea Spain Ethiopia Finland Fiji Micronesia(Federated
States of) France Gabon Grenada Georgia Ghana Gambia Guinea Equatorial Guinea
Greece Guatemala Guinea-Bissau Guyana Honduras Croatia Haiti Hungary Indonesia
Ireland Israel India Iraq Iran(Islamic Republic of) Iceland Italy Jamaica Jordan
Japan Kenya Kyrgyzstan Cambodia Kiribati Saint Kitts and Nevis Democratic
People's Republic of Korea Republic of Korea Kuwait Kazakhstan Lao People's
Democratic Republic Lebanon Saint Lucia Liechtenstein Sri Lanka Liberia Lesotho
Lithuania Luxembourg Latvia Libyan Arab Jamahiriya Morocco Monaco Republic of
Moldova Montenegro Madagascar Marshall Islands The former Yugoslav Republic of
Macedonia Mali Myanmar Mongolia Mauritania Malta Mauritius Maldives Malawi
Mexico Malaysia Mozambique Namibia Niger Nigeria Nicaragua Netherlands Norway
Nepal Nauru New Zealand Oman Panama Peru Papua New Guinea Philippines Pakistan
Poland Portugal Palau Paraguay Qatar Romania Serbia Russian Federation Rwanda
Saudi Arabia Solomon Islands Seychelles Sudan Sweden Singapore Slovenia Slovakia
Sierra Leone San Marino Senegal Somalia Suriname South Africa South Sudan Sao
Tome and Principe El Salvador Syrian Arab Republic Eswatini Switzerland Chad
Togo Thailand Tajikistan Timor - Leste Turkmenistan Tunisia Tonga Turkey
Trinidad and Tobago Tuvalu Taiwan Ukraine Uganda United Arab Emirates United
Kingdom of Great Britain and Northern Ireland United Republic of Tanzania United
States of America Uruguay Uzbekistan Saint Vincent and the Grenadines
Venezuela(Bolivarian Republic of) Viet Nam Vanuatu Samoa Yemen Zambia Zimbabwe
3
CURRENT COMPANY CONTACT (NAME AND TITLE)
--------------------------------------------------------------------------------
First Name
Middle Initial
Last Name
Title
4
OFFICE PHONE NUMBER
--------------------------------------------------------------------------------
Office Phone Number
Phone
5
COMPANY CONTACT EMAIL ADDRESS
--------------------------------------------------------------------------------
Email Address
HEALTH PLAN DETAILS
Please do your best to provide as much information as you can below. While more
information will assist the Claims Administrator in processing your claim, only
boxes marked with an * are required.
1
HEALTH PLAN ENTRY
Delete Entry
--------------------------------------------------------------------------------
Health Plan Name Anthem Blue Cross Life and Health Insurance Company Anthem
Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of
Kentucky) Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue
Shield (of Maine) Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue
Cross and Blue Shield (of New Hampshire) Anthem Health Plans of Virginia, Inc.
d/b/a Anthem Blue Cross and Blue Shield (of Virginia) Anthem Health Plans, Inc.
d/b/a Anthem Blue Cross and Blue Shield (of Connecticut) Anthem Insurance
Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana) Arkansas
Blue Cross and Blue Shield Blue Benefits Administrators Blue Care Network of
Michigan Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company
Blue Cross & Blue Shield of Rhode Island Blue Cross and Blue Shield of Alabama
Blue Cross and Blue Shield of Georgia, Inc. Blue Cross and Blue Shield of
Illinois Blue Cross and Blue Shield of Kansas Blue Cross and Blue Shield of
Kansas City Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Blue
Cross and Blue Shield of Massachusetts, Inc. Blue Cross and Blue Shield of
Minnesota Blue Cross and Blue Shield of Montana Blue Cross and Blue Shield of
New Mexico Blue Cross and Blue Shield of North Carolina Blue Cross and Blue
Shield of Oklahoma Blue Cross and Blue Shield of Texas Blue Cross and Blue
Shield of Vermont Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a
Anthem Blue Cross and Blue Shield Blue Cross Blue Shield of Delaware Blue Cross
Blue Shield of Louisiana Blue Cross Blue Shield of Massachusetts Blue Cross Blue
Shield of Michigan Blue Cross Blue Shield of Nebraska Blue Cross Blue Shield of
North Dakota Blue Cross Blue Shield of Northeastern Pennsylvania Blue Cross Blue
Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield Blue Cross Blue
Shield of Wyoming Blue Cross of California d/b/a Anthem Blue Cross Blue Cross of
Idaho Blue Plus Blue Shield of California Blue Shield of California Life &
Health Insurance Company BlueAdvantage Administrators of Arkansas BlueChoice
HealthPlan of South Carolina BlueCross BlueShield of Arizona BlueCross
BlueShield of Florida, Inc. BlueCross BlueShield of South Carolina BlueCross
BlueShield of Tennessee BlueCross BlueShield of Western New York BlueShield of
Northeastern New York California Physicians’ Service dba Blue Shield of
California Capital Advantage Assurance Company (CAAC) Capital Advantage
Insurance Company (CAIC) Capital BlueCross Capital Health Plan, Inc. CareFirst
BlueChoice, Inc. CareFirst BlueCross BlueShield DC/Montgomery County/Prince
George’s County/Virginia CareFirst BlueCross BlueShield Maryland CareFirst of
Maryland, Inc. (CFMI) CBA Blue (Vermont) CFA LLC Claim Management Services, Inc.
d/b/a Anthem Blue Cross and Blue Shield Community Insurance Company d/b/a Anthem
Blue Cross and Blue Shield (of Ohio) Compcare Health Services Insurance
Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of Wisconsin) Empire
HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield Empire
HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield Excellus BlueCross
BlueShield First Priority Health First Priority Life Florida Blue Florida Health
Care Plan, Inc. Group Hospitalization and Medical Services, Inc. (GHMSI) Hawaii
Medical Service Association (HMSA) Health Advantage HealthKeepers, Inc.
Healthwise Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and
Blue Shield (of Missouri) Highmark Blue Cross Blue Shield Highmark Blue Cross
Blue Shield of Delaware Highmark Blue Cross Blue Shield of West Virginia
Highmark Blue Shield HMO Colorado, Inc. HMO Colorado, Inc. d/b/a HMO Nevada,
Inc. HMO Louisiana, Inc. HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue
Shield (of Missouri) HMO Partners, Inc. Horizon Blue Cross Blue Shield of New
Jersey Independence Administrators Independence Blue Cross Independence Hospital
Indemnity Plan Keystone Health Plan Central, Inc. (KHPC) Keystone Health Plan
East Keystone Health Plan West Matthew Thornton Health Plan, Inc. Mountain State
Blue Cross Blue Shield Premera Blue Cross Premera Blue Cross Blue Shield Premera
Blue Cross Blue Shield of Alaska QCC Insurance Company Regence BlueCross
BlueShield of Oregon Regence BlueCross BlueShield of Utah Regence BlueShield
Regence BlueShield of Idaho Regence Group Administrators Regence Health
Maintenance of Oregon Regence HMO Oregon Regence Life and Health Insurance
Company Regence ValueCare RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross
and Blue Shield Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem
Blue Cross and Blue Shield (of Colorado) Triple-S Management Corp. Triple-S
Salud, Inc. USAble Mutual Insurance Company Wellmark BCBS of Iowa Wellmark BCBS
of South Dakota Wellmark Health Plan of Iowa Wellmark Synergy Health Plan
Wellmark Value Health Plan Wisconsin Collaborative Insurance Company Other
Other Health Plan Name
Group #
Coverage Start Date
Coverage End Date
Was this plan purchased through a Purchasing Entity ?
Yes No
Check this box if your company/business/entity acquired its health plan through
another purchasing entity, such as a Professional Employer Organization ("PEO").
Purchasing Entity
Check this box if you are a PEO, Union, Trade Association, or other
associational entity that collected payment for, contracted with or purchased a
BCBS health insurance or administrative services plan on behalf of your client
companies, customers or members directly from a BCBS company.
Show More… Show Less…
--------------------------------------------------------------------------------
Group # field is required.
LocKey_CoverageStartDateRequiredErrMsgRequiredErrMsg
LocKey_CoverageEndDateRequiredErrMsgRequiredErrMsg
Add another Health Plan
HEALTH PLAN ENTRY
Delete Entry
--------------------------------------------------------------------------------
Health Plan Name Anthem Blue Cross Life and Health Insurance Company Anthem
Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of
Kentucky) Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue
Shield (of Maine) Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue
Cross and Blue Shield (of New Hampshire) Anthem Health Plans of Virginia, Inc.
d/b/a Anthem Blue Cross and Blue Shield (of Virginia) Anthem Health Plans, Inc.
d/b/a Anthem Blue Cross and Blue Shield (of Connecticut) Anthem Insurance
Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana) Arkansas
Blue Cross and Blue Shield Blue Benefits Administrators Blue Care Network of
Michigan Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company
Blue Cross & Blue Shield of Rhode Island Blue Cross and Blue Shield of Alabama
Blue Cross and Blue Shield of Georgia, Inc. Blue Cross and Blue Shield of
Illinois Blue Cross and Blue Shield of Kansas Blue Cross and Blue Shield of
Kansas City Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Blue
Cross and Blue Shield of Massachusetts, Inc. Blue Cross and Blue Shield of
Minnesota Blue Cross and Blue Shield of Montana Blue Cross and Blue Shield of
New Mexico Blue Cross and Blue Shield of North Carolina Blue Cross and Blue
Shield of Oklahoma Blue Cross and Blue Shield of Texas Blue Cross and Blue
Shield of Vermont Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a
Anthem Blue Cross and Blue Shield Blue Cross Blue Shield of Delaware Blue Cross
Blue Shield of Louisiana Blue Cross Blue Shield of Massachusetts Blue Cross Blue
Shield of Michigan Blue Cross Blue Shield of Nebraska Blue Cross Blue Shield of
North Dakota Blue Cross Blue Shield of Northeastern Pennsylvania Blue Cross Blue
Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield Blue Cross Blue
Shield of Wyoming Blue Cross of California d/b/a Anthem Blue Cross Blue Cross of
Idaho Blue Plus Blue Shield of California Blue Shield of California Life &
Health Insurance Company BlueAdvantage Administrators of Arkansas BlueChoice
HealthPlan of South Carolina BlueCross BlueShield of Arizona BlueCross
BlueShield of Florida, Inc. BlueCross BlueShield of South Carolina BlueCross
BlueShield of Tennessee BlueCross BlueShield of Western New York BlueShield of
Northeastern New York California Physicians’ Service dba Blue Shield of
California Capital Advantage Assurance Company (CAAC) Capital Advantage
Insurance Company (CAIC) Capital BlueCross Capital Health Plan, Inc. CareFirst
BlueChoice, Inc. CareFirst BlueCross BlueShield DC/Montgomery County/Prince
George’s County/Virginia CareFirst BlueCross BlueShield Maryland CareFirst of
Maryland, Inc. (CFMI) CBA Blue (Vermont) CFA LLC Claim Management Services, Inc.
d/b/a Anthem Blue Cross and Blue Shield Community Insurance Company d/b/a Anthem
Blue Cross and Blue Shield (of Ohio) Compcare Health Services Insurance
Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of Wisconsin) Empire
HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield Empire
HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield Excellus BlueCross
BlueShield First Priority Health First Priority Life Florida Blue Florida Health
Care Plan, Inc. Group Hospitalization and Medical Services, Inc. (GHMSI) Hawaii
Medical Service Association (HMSA) Health Advantage HealthKeepers, Inc.
Healthwise Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and
Blue Shield (of Missouri) Highmark Blue Cross Blue Shield Highmark Blue Cross
Blue Shield of Delaware Highmark Blue Cross Blue Shield of West Virginia
Highmark Blue Shield HMO Colorado, Inc. HMO Colorado, Inc. d/b/a HMO Nevada,
Inc. HMO Louisiana, Inc. HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue
Shield (of Missouri) HMO Partners, Inc. Horizon Blue Cross Blue Shield of New
Jersey Independence Administrators Independence Blue Cross Independence Hospital
Indemnity Plan Keystone Health Plan Central, Inc. (KHPC) Keystone Health Plan
East Keystone Health Plan West Matthew Thornton Health Plan, Inc. Mountain State
Blue Cross Blue Shield Premera Blue Cross Premera Blue Cross Blue Shield Premera
Blue Cross Blue Shield of Alaska QCC Insurance Company Regence BlueCross
BlueShield of Oregon Regence BlueCross BlueShield of Utah Regence BlueShield
Regence BlueShield of Idaho Regence Group Administrators Regence Health
Maintenance of Oregon Regence HMO Oregon Regence Life and Health Insurance
Company Regence ValueCare RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross
and Blue Shield Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem
Blue Cross and Blue Shield (of Colorado) Triple-S Management Corp. Triple-S
Salud, Inc. USAble Mutual Insurance Company Wellmark BCBS of Iowa Wellmark BCBS
of South Dakota Wellmark Health Plan of Iowa Wellmark Synergy Health Plan
Wellmark Value Health Plan Wisconsin Collaborative Insurance Company Other
Other Health Plan Name
Group #
Coverage Start Date
Coverage End Date
Was this plan purchased through a Purchasing Entity ?
Yes No
Check this box if your company/business/entity acquired its health plan through
another purchasing entity, such as a Professional Employer Organization ("PEO").
Purchasing Entity
Check this box if you are a PEO, Union, Trade Association, or other
associational entity that collected payment for, contracted with or purchased a
BCBS health insurance or administrative services plan on behalf of your client
companies, customers or members directly from a BCBS company.
Show More… Show Less…
ALLOCATION OF PREMIUMS
The Settlement provides that payments will be based, in part, on premiums paid
for BCBS health insurance or administrative services plans during the relevant
periods between February 2008 and October 2020 for fully insured plans, and
between September 2015 and October 2020 for administrative services plans.
The Settlement further provides default formulas for the Claims Administrator to
use when determining what percentage of the premium was paid by an
employer/entity and what percentage was contributed by its employees/members.
If you accept the Default option , you are NOT required to provide any
additional data or evidence in support of your claim at this time. If another
claimant’s filing affects your claim, you will be provided with an opportunity
to respond at a later date.
If you proceed with the Alternative option , you must also provide data or
evidence to support the alternative contribution percentages you provide. If you
select this option, for any time period for which supporting data or evidence is
not provided, the Default Option will be applied.
ACCEPT THE DEFAULT OPTION
APPLY FOR AN ALTERNATIVE CONTRIBUTION %
STOP: If you want to use the DEFAULT OPTION, DO NOT FILL OUT THIS SECTION.
Instead, click HERE.
1
ALTERNATIVE OPTION
--------------------------------------------------------------------------------
Please state the percentage contribution you believe you contributed for each
year that you were enrolled in a BCBS health insurance or administrative
services plan.
Plan Year
Contribution
--------------------------------------------------------------------------------
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
%
ADD ANOTHER YEAR
2
UPLOAD SUPPORTING DOCUMENTATION
--------------------------------------------------------------------------------
If you choose to apply for an alternative contribution percentage you must
supply documentation with this claim form supporting the percentage you claim to
have contributed. If you do not submit supporting documentation the Default
contribution rates will be applied to your claim.
Check this box if you want to upload your documents later.
Supported files include: .jpg, .jpeg, .pdf, .png, .tif, and .tiff. Maximum
upload size is 10MB
DELETE FILE
ADD ANOTHER FILE
ALTERNATIVE CONTRIBUTION
×
If you choose to apply for an alternative contribution percentage, you must
supply documentation with this claim form supporting the percentage you claim to
have contributed. If you do not provide additional documentation, the Default
Option will be applied to your claim.
Selection of the Alternative Option does not ensure a contribution percentage
higher than or equal to the Default Option. Your percentage will be dependent on
a process that includes a review of all materials submitted pertaining to your
premium.
Are you sure you want to apply for an alternative contribution percentage?
Continue with alternative option
Switch to the default option
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
%
Delete Entry
DELETE FILE
PAYMENT ELECTION
Please let us know how you would like to receive your settlement payment if your
claim is deemed valid.
Final determinations of claim amounts will not be made until after processing by
the Claims Administrator is complete. Claims will not be paid if the value is
equal to or less than $5.00.
Claimants who submit valid, approved claims shall receive a pro-rata percentage
of the Net Settlement Fund allocated to their type of coverage (fully-insured or
self-funded) based upon their estimated proportion of the cumulative total of
premiums and/or administrative fees paid by all claimants.
Payment Option Please Select Venmo PayPal Pre-paid Card Check
Venmo Username
PayPal Email
CONFIRMATION
Your claim form has been submitted successfully. Please keep the Claim Number
below for your records.
Claim Number:
SUPPORTING DOCUMENTATION
Print a Copy of Your Claim
REVIEW
Please review your claim information below. If you need to make any edits to
your claim, you may go back to a page by clicking that section of the progress
bar or clicking the Back button at the bottom of the page. If everything is
correct, complete the Signature section at the bottom of the page and click the
Submit button.
BUSINESS INFORMATION
FULL NAME OF COMPANY
--------------------------------------------------------------------------------
Company
PRIMARY HEADQUARTERS MAILING ADDRESS
--------------------------------------------------------------------------------
Street Line 1
Street Line 2
City
State
Zip
Province
Postal Code
Country
CURRENT COMPANY CONTACT (NAME AND TITLE)
--------------------------------------------------------------------------------
First Name
Middle Initial
Last Name
Title
OFFICE PHONE NUMBER
--------------------------------------------------------------------------------
Phone
Phone
COMPANY CONTACT EMAIL ADDRESS
--------------------------------------------------------------------------------
Email Address
HEALTH PLAN DETAILS
ALLOCATION OF PREMIUMS
ALTERNATIVE CONTRIBUTION % SELECTED
DEFAULT OPTION SELECTED
ALTERNATIVE OPTION
--------------------------------------------------------------------------------
Plan Year
Contribution
--------------------------------------------------------------------------------
UPLOAD SUPPORTING DOCUMENTATION
--------------------------------------------------------------------------------
Please Wait For Upload
Upload Failed For Files
PAYMENT ELECTION
Payment Option
Venmo Username
PayPal Email
SIGNATURE
By checking this box, I affirm under the laws of the United States and the laws
of my State of residence that the information supplied in this Claim Form by the
undersigned is true and correct to the best of my recollection, and that this
form was executed on the date set forth below.
By checking this box, I understand that I may be asked to provide supplemental
information to the Claims Administrator and/or Settlement Administrator before
my claim will be considered complete and valid.
Type your name in the box below to electronically sign your claim
Date
Company Title
--------------------------------------------------------------------------------
Health Plan Name
Group #
Coverage Start Date
Coverage End Date
Was this plan purchased through a Purchasing Entity?
Check this box if your company/business/entity acquired its health plan through
another purchasing entity, such as a Professional Employer Organization ("PEO").
Purchasing Entity
Check this box if you are a PEO, Union, Trade Association, or other
associational entity that collected payment for, contracted with or purchased a
BCBS health insurance or administrative services plan on behalf of your client
companies, customers or members directly from a BCBS company.
%
ERROR
Your Claim Form Has Not Been Submitted
SUBSCRIBER INFORMATION
First Name
Middle Initial
Last Name
Street Line 1
Street Line 2
City
State Alabama Alaska American Samoa Arizona Arkansas California Colorado
Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho
Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts
Michigan Minnesota Mississippi Missouri Northern Mariana Islands Montana
Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina
North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South
Carolina South Dakota Tennessee Texas Utah Vermont Virginia U.S. Virgin Islands
Washington West Virginia Wisconsin Wyoming AA AP AE
Province
Zip
Postal Code
Country Andorra Afghanistan Antigua and Barbuda Albania Armenia Angola Argentina
Austria Australia Azerbaijan Bosnia and Herzegovina Barbados Bangladesh Belgium
Burkina Faso Bulgaria Bahrain Burundi Benin Brunei Darussalam
Bolivia(Plurinational State of) Brazil Bahamas Bhutan Botswana Belarus Belize
Canada Central African Republic Congo Côte d'Ivoire Cape Verde Chile Cameroon
China Colombia Costa Rica Cuba Comoros Cyprus Czech Republic Germany Djibouti
Democratic Republic of the Congo Denmark Dominica Dominican Republic Algeria
Ecuador Estonia Egypt Eritrea Spain Ethiopia Finland Fiji Micronesia(Federated
States of) France Gabon Grenada Georgia Ghana Gambia Guinea Equatorial Guinea
Greece Guatemala Guinea-Bissau Guyana Honduras Croatia Haiti Hungary Indonesia
Ireland Israel India Iraq Iran(Islamic Republic of) Iceland Italy Jamaica Jordan
Japan Kenya Kyrgyzstan Cambodia Kiribati Saint Kitts and Nevis Democratic
People's Republic of Korea Republic of Korea Kuwait Kazakhstan Lao People's
Democratic Republic Lebanon Saint Lucia Liechtenstein Sri Lanka Liberia Lesotho
Lithuania Luxembourg Latvia Libyan Arab Jamahiriya Morocco Monaco Republic of
Moldova Montenegro Madagascar Marshall Islands The former Yugoslav Republic of
Macedonia Mali Myanmar Mongolia Mauritania Malta Mauritius Maldives Malawi
Mexico Malaysia Mozambique Namibia Niger Nigeria Nicaragua Netherlands Norway
Nepal Nauru New Zealand Oman Panama Peru Papua New Guinea Philippines Pakistan
Poland Portugal Palau Paraguay Qatar Romania Serbia Russian Federation Rwanda
Saudi Arabia Solomon Islands Seychelles Sudan Sweden Singapore Slovenia Slovakia
Sierra Leone San Marino Senegal Somalia Suriname South Africa South Sudan Sao
Tome and Principe El Salvador Syrian Arab Republic Eswatini Switzerland Chad
Togo Thailand Tajikistan Timor - Leste Turkmenistan Tunisia Tonga Turkey
Trinidad and Tobago Tuvalu Taiwan Ukraine Uganda United Arab Emirates United
Kingdom of Great Britain and Northern Ireland United Republic of Tanzania United
States of America Uruguay Uzbekistan Saint Vincent and the Grenadines
Venezuela(Bolivarian Republic of) Viet Nam Vanuatu Samoa Yemen Zambia Zimbabwe
Phone
Phone
Email
HEALTH PLAN DETAILS
Please do your best to provide as much information as you can below. While more
information will assist the Claims Administrator in processing your claim, only
boxes marked with an * are required.
1
HEALTH PLAN ENTRY
Delete Entry
--------------------------------------------------------------------------------
Health Plan Name Anthem Blue Cross Life and Health Insurance Company Anthem
Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of
Kentucky) Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue
Shield (of Maine) Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue
Cross and Blue Shield (of New Hampshire) Anthem Health Plans of Virginia, Inc.
d/b/a Anthem Blue Cross and Blue Shield (of Virginia) Anthem Health Plans, Inc.
d/b/a Anthem Blue Cross and Blue Shield (of Connecticut) Anthem Insurance
Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana) Arkansas
Blue Cross and Blue Shield Blue Benefits Administrators Blue Care Network of
Michigan Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company
Blue Cross & Blue Shield of Rhode Island Blue Cross and Blue Shield of Alabama
Blue Cross and Blue Shield of Georgia, Inc. Blue Cross and Blue Shield of
Illinois Blue Cross and Blue Shield of Kansas Blue Cross and Blue Shield of
Kansas City Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Blue
Cross and Blue Shield of Massachusetts, Inc. Blue Cross and Blue Shield of
Minnesota Blue Cross and Blue Shield of Montana Blue Cross and Blue Shield of
New Mexico Blue Cross and Blue Shield of North Carolina Blue Cross and Blue
Shield of Oklahoma Blue Cross and Blue Shield of Texas Blue Cross and Blue
Shield of Vermont Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a
Anthem Blue Cross and Blue Shield Blue Cross Blue Shield of Delaware Blue Cross
Blue Shield of Louisiana Blue Cross Blue Shield of Massachusetts Blue Cross Blue
Shield of Michigan Blue Cross Blue Shield of Nebraska Blue Cross Blue Shield of
North Dakota Blue Cross Blue Shield of Northeastern Pennsylvania Blue Cross Blue
Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield Blue Cross Blue
Shield of Wyoming Blue Cross of California d/b/a Anthem Blue Cross Blue Cross of
Idaho Blue Plus Blue Shield of California Blue Shield of California Life &
Health Insurance Company BlueAdvantage Administrators of Arkansas BlueChoice
HealthPlan of South Carolina BlueCross BlueShield of Arizona BlueCross
BlueShield of Florida, Inc. BlueCross BlueShield of South Carolina BlueCross
BlueShield of Tennessee BlueCross BlueShield of Western New York BlueShield of
Northeastern New York California Physicians’ Service dba Blue Shield of
California Capital Advantage Assurance Company (CAAC) Capital Advantage
Insurance Company (CAIC) Capital BlueCross Capital Health Plan, Inc. CareFirst
BlueChoice, Inc. CareFirst BlueCross BlueShield DC/Montgomery County/Prince
George’s County/Virginia CareFirst BlueCross BlueShield Maryland CareFirst of
Maryland, Inc. (CFMI) CBA Blue (Vermont) CFA LLC Claim Management Services, Inc.
d/b/a Anthem Blue Cross and Blue Shield Community Insurance Company d/b/a Anthem
Blue Cross and Blue Shield (of Ohio) Compcare Health Services Insurance
Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of Wisconsin) Empire
HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield Empire
HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield Excellus BlueCross
BlueShield First Priority Health First Priority Life Florida Blue Florida Health
Care Plan, Inc. Group Hospitalization and Medical Services, Inc. (GHMSI) Hawaii
Medical Service Association (HMSA) Health Advantage HealthKeepers, Inc.
Healthwise Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and
Blue Shield (of Missouri) Highmark Blue Cross Blue Shield Highmark Blue Cross
Blue Shield of Delaware Highmark Blue Cross Blue Shield of West Virginia
Highmark Blue Shield HMO Colorado, Inc. HMO Colorado, Inc. d/b/a HMO Nevada,
Inc. HMO Louisiana, Inc. HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue
Shield (of Missouri) HMO Partners, Inc. Horizon Blue Cross Blue Shield of New
Jersey Independence Administrators Independence Blue Cross Independence Hospital
Indemnity Plan Keystone Health Plan Central, Inc. (KHPC) Keystone Health Plan
East Keystone Health Plan West Matthew Thornton Health Plan, Inc. Mountain State
Blue Cross Blue Shield Premera Blue Cross Premera Blue Cross Blue Shield Premera
Blue Cross Blue Shield of Alaska QCC Insurance Company Regence BlueCross
BlueShield of Oregon Regence BlueCross BlueShield of Utah Regence BlueShield
Regence BlueShield of Idaho Regence Group Administrators Regence Health
Maintenance of Oregon Regence HMO Oregon Regence Life and Health Insurance
Company Regence ValueCare RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross
and Blue Shield Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem
Blue Cross and Blue Shield (of Colorado) Triple-S Management Corp. Triple-S
Salud, Inc. USAble Mutual Insurance Company Wellmark BCBS of Iowa Wellmark BCBS
of South Dakota Wellmark Health Plan of Iowa Wellmark Synergy Health Plan
Wellmark Value Health Plan Wisconsin Collaborative Insurance Company Other
Other Health Plan Name
Group #
Employer Name
Employer Address
Subscriber or Member ID
Coverage Start Date
Coverage End Date
--------------------------------------------------------------------------------
Group # field is required.
LocKey_CoverageStartDateRequiredErrMsgRequiredErrMsg
LocKey_CoverageEndDateRequiredErrMsgRequiredErrMsg
Add another Health Plan
HEALTH PLAN ENTRY
Delete Entry
--------------------------------------------------------------------------------
Health Plan Name Anthem Blue Cross Life and Health Insurance Company Anthem
Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of
Kentucky) Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue
Shield (of Maine) Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue
Cross and Blue Shield (of New Hampshire) Anthem Health Plans of Virginia, Inc.
d/b/a Anthem Blue Cross and Blue Shield (of Virginia) Anthem Health Plans, Inc.
d/b/a Anthem Blue Cross and Blue Shield (of Connecticut) Anthem Insurance
Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana) Arkansas
Blue Cross and Blue Shield Blue Benefits Administrators Blue Care Network of
Michigan Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company
Blue Cross & Blue Shield of Rhode Island Blue Cross and Blue Shield of Alabama
Blue Cross and Blue Shield of Georgia, Inc. Blue Cross and Blue Shield of
Illinois Blue Cross and Blue Shield of Kansas Blue Cross and Blue Shield of
Kansas City Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Blue
Cross and Blue Shield of Massachusetts, Inc. Blue Cross and Blue Shield of
Minnesota Blue Cross and Blue Shield of Montana Blue Cross and Blue Shield of
New Mexico Blue Cross and Blue Shield of North Carolina Blue Cross and Blue
Shield of Oklahoma Blue Cross and Blue Shield of Texas Blue Cross and Blue
Shield of Vermont Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a
Anthem Blue Cross and Blue Shield Blue Cross Blue Shield of Delaware Blue Cross
Blue Shield of Louisiana Blue Cross Blue Shield of Massachusetts Blue Cross Blue
Shield of Michigan Blue Cross Blue Shield of Nebraska Blue Cross Blue Shield of
North Dakota Blue Cross Blue Shield of Northeastern Pennsylvania Blue Cross Blue
Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield Blue Cross Blue
Shield of Wyoming Blue Cross of California d/b/a Anthem Blue Cross Blue Cross of
Idaho Blue Plus Blue Shield of California Blue Shield of California Life &
Health Insurance Company BlueAdvantage Administrators of Arkansas BlueChoice
HealthPlan of South Carolina BlueCross BlueShield of Arizona BlueCross
BlueShield of Florida, Inc. BlueCross BlueShield of South Carolina BlueCross
BlueShield of Tennessee BlueCross BlueShield of Western New York BlueShield of
Northeastern New York California Physicians’ Service dba Blue Shield of
California Capital Advantage Assurance Company (CAAC) Capital Advantage
Insurance Company (CAIC) Capital BlueCross Capital Health Plan, Inc. CareFirst
BlueChoice, Inc. CareFirst BlueCross BlueShield DC/Montgomery County/Prince
George’s County/Virginia CareFirst BlueCross BlueShield Maryland CareFirst of
Maryland, Inc. (CFMI) CBA Blue (Vermont) CFA LLC Claim Management Services, Inc.
d/b/a Anthem Blue Cross and Blue Shield Community Insurance Company d/b/a Anthem
Blue Cross and Blue Shield (of Ohio) Compcare Health Services Insurance
Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of Wisconsin) Empire
HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield Empire
HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield Excellus BlueCross
BlueShield First Priority Health First Priority Life Florida Blue Florida Health
Care Plan, Inc. Group Hospitalization and Medical Services, Inc. (GHMSI) Hawaii
Medical Service Association (HMSA) Health Advantage HealthKeepers, Inc.
Healthwise Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and
Blue Shield (of Missouri) Highmark Blue Cross Blue Shield Highmark Blue Cross
Blue Shield of Delaware Highmark Blue Cross Blue Shield of West Virginia
Highmark Blue Shield HMO Colorado, Inc. HMO Colorado, Inc. d/b/a HMO Nevada,
Inc. HMO Louisiana, Inc. HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue
Shield (of Missouri) HMO Partners, Inc. Horizon Blue Cross Blue Shield of New
Jersey Independence Administrators Independence Blue Cross Independence Hospital
Indemnity Plan Keystone Health Plan Central, Inc. (KHPC) Keystone Health Plan
East Keystone Health Plan West Matthew Thornton Health Plan, Inc. Mountain State
Blue Cross Blue Shield Premera Blue Cross Premera Blue Cross Blue Shield Premera
Blue Cross Blue Shield of Alaska QCC Insurance Company Regence BlueCross
BlueShield of Oregon Regence BlueCross BlueShield of Utah Regence BlueShield
Regence BlueShield of Idaho Regence Group Administrators Regence Health
Maintenance of Oregon Regence HMO Oregon Regence Life and Health Insurance
Company Regence ValueCare RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross
and Blue Shield Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem
Blue Cross and Blue Shield (of Colorado) Triple-S Management Corp. Triple-S
Salud, Inc. USAble Mutual Insurance Company Wellmark BCBS of Iowa Wellmark BCBS
of South Dakota Wellmark Health Plan of Iowa Wellmark Synergy Health Plan
Wellmark Value Health Plan Wisconsin Collaborative Insurance Company Other
Other Health Plan Name
Group #
Employer Name
Employer Address
Subscriber or Member ID
Coverage Start Date
Coverage End Date
ALLOCATION OF PREMIUMS
The Settlement provides that payments will be based, in part, on premiums paid
for BCBS health insurance or administrative services plans during the relevant
periods between February 2008 and October 2020 for fully insured plans, and
between September 2015 and October 2020 for administrative services plans.
The Settlement further provides default formulas for the Claims Administrator to
use when determining what percentage of the premium was paid by an
employer/entity and what percentage was contributed by its employees/members.
If you accept the Default option , you are NOT required to provide any
additional data or evidence in support of your claim at this time. If another
claimant’s filing affects your claim, you will be provided with an opportunity
to respond at a later date.
If you proceed with the Alternative option , you must also provide data or
evidence to support the alternative contribution percentages you provide. If you
select this option, for any time period for which supporting data or evidence is
not provided, the Default Option will be applied.
ACCEPT THE DEFAULT OPTION
APPLY FOR AN ALTERNATIVE CONTRIBUTION %
STOP: If you want to use the DEFAULT OPTION, DO NOT FILL OUT THIS SECTION.
Instead, click HERE.
1
ALTERNATIVE OPTION
--------------------------------------------------------------------------------
Please state the percentage contribution you believe you contributed for each
year that you were enrolled in a BCBS health insurance or administrative
services plan.
Plan Year
Contribution
--------------------------------------------------------------------------------
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
%
ADD ANOTHER YEAR
2
UPLOAD SUPPORTING DOCUMENTATION
--------------------------------------------------------------------------------
If you choose to apply for an alternative contribution percentage you must
supply documentation with this claim form supporting the percentage you claim to
have contributed. If you do not submit supporting documentation the Default
contribution rates will be applied to your claim.
Check this box if you want to upload your documents later.
Supported files include: .jpg, .jpeg, .pdf, .png, .tif, and .tiff. Maximum
upload size is 10MB
DELETE FILE
ADD ANOTHER FILE
ALTERNATIVE CONTRIBUTION
×
If you choose to apply for an alternative contribution percentage, you must
supply documentation with this claim form supporting the percentage you claim to
have contributed. If you do not provide additional documentation, the Default
Option will be applied to your claim.
Selection of the Alternative Option does not ensure a contribution percentage
higher than or equal to the Default Option. Your percentage will be dependent on
a process that includes a review of all materials submitted pertaining to your
premium.
Are you sure you want to apply for an alternative contribution percentage?
Continue with alternative option
Switch to the default option
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
%
Delete Entry
DELETE FILE
PAYMENT ELECTION
Please let us know how you would like to receive your settlement payment if your
claim is deemed valid.
Final determinations of claim amounts will not be made until after processing by
the Claims Administrator is complete. Claims will not be paid if the value is
equal to or less than $5.00.
Claimants who submit valid, approved claims shall receive a pro-rata percentage
of the Net Settlement Fund allocated to their type of coverage (fully-insured or
self-funded) based upon their estimated proportion of the cumulative total of
premiums and/or administrative fees paid by all claimants.
Payment Option Please Select Venmo PayPal Pre-paid Card Check
Venmo Username
PayPal Email
CONFIRMATION
Your claim form has been submitted successfully. Please keep the Claim Number
below for your records.
Claim Number:
SUPPORTING DOCUMENTATION
Print a Copy of Your Claim
REVIEW
Please review your claim information below. If you need to make any edits to
your claim, you may go back to a page by clicking that section of the progress
bar or clicking the Back button at the bottom of the page. If everything is
correct, complete the Signature section at the bottom of the page and click the
Submit button.
SUBSCRIBER INFORMATION
MAILING ADDRESS
--------------------------------------------------------------------------------
Street Line 1
Street Line 2
City
State
Zip
Province
Postal Code
Country
SUBSCRIBER NAME
--------------------------------------------------------------------------------
First Name
Middle Initial
Last Name
PHONE NUMBER
--------------------------------------------------------------------------------
Phone
Phone
EMAIL ADDRESS
--------------------------------------------------------------------------------
Email
HEALTH PLAN DETAILS
ALLOCATION OF PREMIUMS
ALTERNATIVE CONTRIBUTION % SELECTED
DEFAULT OPTION SELECTED
ALTERNATIVE OPTION
--------------------------------------------------------------------------------
Plan Year
Contribution
--------------------------------------------------------------------------------
UPLOAD SUPPORTING DOCUMENTATION
--------------------------------------------------------------------------------
Please Wait For Upload
Upload Failed For Files
PAYMENT ELECTION
Payment Option
Venmo Username
PayPal Email
SIGNATURE
By checking this box, I affirm under the laws of the United States and the laws
of my State of residence that the information supplied in this Claim Form by the
undersigned is true and correct to the best of my recollection, and that this
form was executed on the date set forth below.
By checking this box, I understand that I may be asked to provide supplemental
information to the Claims Administrator and/or Settlement Administrator before
my claim will be considered complete and valid.
Type your name in the box below to electronically sign your claim
Date
--------------------------------------------------------------------------------
Health Plan Name
Group #
Coverage Start Date
Coverage End Date
Employer Name
Employer Address
Subscriber or Member ID
%
ERROR
Your Claim Form Has Not Been Submitted
SUBSCRIBER INFORMATION
First Name
Middle Initial
Last Name
Street Line 1
Street Line 2
City
State Alabama Alaska American Samoa Arizona Arkansas California Colorado
Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho
Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts
Michigan Minnesota Mississippi Missouri Northern Mariana Islands Montana
Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina
North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South
Carolina South Dakota Tennessee Texas Utah Vermont Virginia U.S. Virgin Islands
Washington West Virginia Wisconsin Wyoming AA AP AE
Province
Zip
Postal Code
Country Andorra Afghanistan Antigua and Barbuda Albania Armenia Angola Argentina
Austria Australia Azerbaijan Bosnia and Herzegovina Barbados Bangladesh Belgium
Burkina Faso Bulgaria Bahrain Burundi Benin Brunei Darussalam
Bolivia(Plurinational State of) Brazil Bahamas Bhutan Botswana Belarus Belize
Canada Central African Republic Congo Côte d'Ivoire Cape Verde Chile Cameroon
China Colombia Costa Rica Cuba Comoros Cyprus Czech Republic Germany Djibouti
Democratic Republic of the Congo Denmark Dominica Dominican Republic Algeria
Ecuador Estonia Egypt Eritrea Spain Ethiopia Finland Fiji Micronesia(Federated
States of) France Gabon Grenada Georgia Ghana Gambia Guinea Equatorial Guinea
Greece Guatemala Guinea-Bissau Guyana Honduras Croatia Haiti Hungary Indonesia
Ireland Israel India Iraq Iran(Islamic Republic of) Iceland Italy Jamaica Jordan
Japan Kenya Kyrgyzstan Cambodia Kiribati Saint Kitts and Nevis Democratic
People's Republic of Korea Republic of Korea Kuwait Kazakhstan Lao People's
Democratic Republic Lebanon Saint Lucia Liechtenstein Sri Lanka Liberia Lesotho
Lithuania Luxembourg Latvia Libyan Arab Jamahiriya Morocco Monaco Republic of
Moldova Montenegro Madagascar Marshall Islands The former Yugoslav Republic of
Macedonia Mali Myanmar Mongolia Mauritania Malta Mauritius Maldives Malawi
Mexico Malaysia Mozambique Namibia Niger Nigeria Nicaragua Netherlands Norway
Nepal Nauru New Zealand Oman Panama Peru Papua New Guinea Philippines Pakistan
Poland Portugal Palau Paraguay Qatar Romania Serbia Russian Federation Rwanda
Saudi Arabia Solomon Islands Seychelles Sudan Sweden Singapore Slovenia Slovakia
Sierra Leone San Marino Senegal Somalia Suriname South Africa South Sudan Sao
Tome and Principe El Salvador Syrian Arab Republic Eswatini Switzerland Chad
Togo Thailand Tajikistan Timor - Leste Turkmenistan Tunisia Tonga Turkey
Trinidad and Tobago Tuvalu Taiwan Ukraine Uganda United Arab Emirates United
Kingdom of Great Britain and Northern Ireland United Republic of Tanzania United
States of America Uruguay Uzbekistan Saint Vincent and the Grenadines
Venezuela(Bolivarian Republic of) Viet Nam Vanuatu Samoa Yemen Zambia Zimbabwe
Phone
Phone
Email
HEALTH PLAN DETAILS
Please do your best to provide as much information as you can below. While more
information will assist the Claims Administrator in processing your claim, only
boxes marked with an * are required.
1
HEALTH PLAN ENTRY
Delete Entry
--------------------------------------------------------------------------------
Health Plan Name Anthem Blue Cross Life and Health Insurance Company Anthem
Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of
Kentucky) Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue
Shield (of Maine) Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue
Cross and Blue Shield (of New Hampshire) Anthem Health Plans of Virginia, Inc.
d/b/a Anthem Blue Cross and Blue Shield (of Virginia) Anthem Health Plans, Inc.
d/b/a Anthem Blue Cross and Blue Shield (of Connecticut) Anthem Insurance
Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana) Arkansas
Blue Cross and Blue Shield Blue Benefits Administrators Blue Care Network of
Michigan Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company
Blue Cross & Blue Shield of Rhode Island Blue Cross and Blue Shield of Alabama
Blue Cross and Blue Shield of Georgia, Inc. Blue Cross and Blue Shield of
Illinois Blue Cross and Blue Shield of Kansas Blue Cross and Blue Shield of
Kansas City Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Blue
Cross and Blue Shield of Massachusetts, Inc. Blue Cross and Blue Shield of
Minnesota Blue Cross and Blue Shield of Montana Blue Cross and Blue Shield of
New Mexico Blue Cross and Blue Shield of North Carolina Blue Cross and Blue
Shield of Oklahoma Blue Cross and Blue Shield of Texas Blue Cross and Blue
Shield of Vermont Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a
Anthem Blue Cross and Blue Shield Blue Cross Blue Shield of Delaware Blue Cross
Blue Shield of Louisiana Blue Cross Blue Shield of Massachusetts Blue Cross Blue
Shield of Michigan Blue Cross Blue Shield of Nebraska Blue Cross Blue Shield of
North Dakota Blue Cross Blue Shield of Northeastern Pennsylvania Blue Cross Blue
Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield Blue Cross Blue
Shield of Wyoming Blue Cross of California d/b/a Anthem Blue Cross Blue Cross of
Idaho Blue Plus Blue Shield of California Blue Shield of California Life &
Health Insurance Company BlueAdvantage Administrators of Arkansas BlueChoice
HealthPlan of South Carolina BlueCross BlueShield of Arizona BlueCross
BlueShield of Florida, Inc. BlueCross BlueShield of South Carolina BlueCross
BlueShield of Tennessee BlueCross BlueShield of Western New York BlueShield of
Northeastern New York California Physicians’ Service dba Blue Shield of
California Capital Advantage Assurance Company (CAAC) Capital Advantage
Insurance Company (CAIC) Capital BlueCross Capital Health Plan, Inc. CareFirst
BlueChoice, Inc. CareFirst BlueCross BlueShield DC/Montgomery County/Prince
George’s County/Virginia CareFirst BlueCross BlueShield Maryland CareFirst of
Maryland, Inc. (CFMI) CBA Blue (Vermont) CFA LLC Claim Management Services, Inc.
d/b/a Anthem Blue Cross and Blue Shield Community Insurance Company d/b/a Anthem
Blue Cross and Blue Shield (of Ohio) Compcare Health Services Insurance
Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of Wisconsin) Empire
HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield Empire
HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield Excellus BlueCross
BlueShield First Priority Health First Priority Life Florida Blue Florida Health
Care Plan, Inc. Group Hospitalization and Medical Services, Inc. (GHMSI) Hawaii
Medical Service Association (HMSA) Health Advantage HealthKeepers, Inc.
Healthwise Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and
Blue Shield (of Missouri) Highmark Blue Cross Blue Shield Highmark Blue Cross
Blue Shield of Delaware Highmark Blue Cross Blue Shield of West Virginia
Highmark Blue Shield HMO Colorado, Inc. HMO Colorado, Inc. d/b/a HMO Nevada,
Inc. HMO Louisiana, Inc. HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue
Shield (of Missouri) HMO Partners, Inc. Horizon Blue Cross Blue Shield of New
Jersey Independence Administrators Independence Blue Cross Independence Hospital
Indemnity Plan Keystone Health Plan Central, Inc. (KHPC) Keystone Health Plan
East Keystone Health Plan West Matthew Thornton Health Plan, Inc. Mountain State
Blue Cross Blue Shield Premera Blue Cross Premera Blue Cross Blue Shield Premera
Blue Cross Blue Shield of Alaska QCC Insurance Company Regence BlueCross
BlueShield of Oregon Regence BlueCross BlueShield of Utah Regence BlueShield
Regence BlueShield of Idaho Regence Group Administrators Regence Health
Maintenance of Oregon Regence HMO Oregon Regence Life and Health Insurance
Company Regence ValueCare RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross
and Blue Shield Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem
Blue Cross and Blue Shield (of Colorado) Triple-S Management Corp. Triple-S
Salud, Inc. USAble Mutual Insurance Company Wellmark BCBS of Iowa Wellmark BCBS
of South Dakota Wellmark Health Plan of Iowa Wellmark Synergy Health Plan
Wellmark Value Health Plan Wisconsin Collaborative Insurance Company Other
Other Health Plan Name
Group #
Subscriber ID
Coverage Start Date
Coverage End Date
--------------------------------------------------------------------------------
Group # field is required.
LocKey_CoverageStartDateRequiredErrMsgRequiredErrMsg
LocKey_CoverageEndDateRequiredErrMsgRequiredErrMsg
Add another Health Plan
HEALTH PLAN ENTRY
Delete Entry
--------------------------------------------------------------------------------
Health Plan Name Anthem Blue Cross Life and Health Insurance Company Anthem
Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of
Kentucky) Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue
Shield (of Maine) Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue
Cross and Blue Shield (of New Hampshire) Anthem Health Plans of Virginia, Inc.
d/b/a Anthem Blue Cross and Blue Shield (of Virginia) Anthem Health Plans, Inc.
d/b/a Anthem Blue Cross and Blue Shield (of Connecticut) Anthem Insurance
Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana) Arkansas
Blue Cross and Blue Shield Blue Benefits Administrators Blue Care Network of
Michigan Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company
Blue Cross & Blue Shield of Rhode Island Blue Cross and Blue Shield of Alabama
Blue Cross and Blue Shield of Georgia, Inc. Blue Cross and Blue Shield of
Illinois Blue Cross and Blue Shield of Kansas Blue Cross and Blue Shield of
Kansas City Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Blue
Cross and Blue Shield of Massachusetts, Inc. Blue Cross and Blue Shield of
Minnesota Blue Cross and Blue Shield of Montana Blue Cross and Blue Shield of
New Mexico Blue Cross and Blue Shield of North Carolina Blue Cross and Blue
Shield of Oklahoma Blue Cross and Blue Shield of Texas Blue Cross and Blue
Shield of Vermont Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a
Anthem Blue Cross and Blue Shield Blue Cross Blue Shield of Delaware Blue Cross
Blue Shield of Louisiana Blue Cross Blue Shield of Massachusetts Blue Cross Blue
Shield of Michigan Blue Cross Blue Shield of Nebraska Blue Cross Blue Shield of
North Dakota Blue Cross Blue Shield of Northeastern Pennsylvania Blue Cross Blue
Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield Blue Cross Blue
Shield of Wyoming Blue Cross of California d/b/a Anthem Blue Cross Blue Cross of
Idaho Blue Plus Blue Shield of California Blue Shield of California Life &
Health Insurance Company BlueAdvantage Administrators of Arkansas BlueChoice
HealthPlan of South Carolina BlueCross BlueShield of Arizona BlueCross
BlueShield of Florida, Inc. BlueCross BlueShield of South Carolina BlueCross
BlueShield of Tennessee BlueCross BlueShield of Western New York BlueShield of
Northeastern New York California Physicians’ Service dba Blue Shield of
California Capital Advantage Assurance Company (CAAC) Capital Advantage
Insurance Company (CAIC) Capital BlueCross Capital Health Plan, Inc. CareFirst
BlueChoice, Inc. CareFirst BlueCross BlueShield DC/Montgomery County/Prince
George’s County/Virginia CareFirst BlueCross BlueShield Maryland CareFirst of
Maryland, Inc. (CFMI) CBA Blue (Vermont) CFA LLC Claim Management Services, Inc.
d/b/a Anthem Blue Cross and Blue Shield Community Insurance Company d/b/a Anthem
Blue Cross and Blue Shield (of Ohio) Compcare Health Services Insurance
Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of Wisconsin) Empire
HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield Empire
HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield Excellus BlueCross
BlueShield First Priority Health First Priority Life Florida Blue Florida Health
Care Plan, Inc. Group Hospitalization and Medical Services, Inc. (GHMSI) Hawaii
Medical Service Association (HMSA) Health Advantage HealthKeepers, Inc.
Healthwise Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and
Blue Shield (of Missouri) Highmark Blue Cross Blue Shield Highmark Blue Cross
Blue Shield of Delaware Highmark Blue Cross Blue Shield of West Virginia
Highmark Blue Shield HMO Colorado, Inc. HMO Colorado, Inc. d/b/a HMO Nevada,
Inc. HMO Louisiana, Inc. HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue
Shield (of Missouri) HMO Partners, Inc. Horizon Blue Cross Blue Shield of New
Jersey Independence Administrators Independence Blue Cross Independence Hospital
Indemnity Plan Keystone Health Plan Central, Inc. (KHPC) Keystone Health Plan
East Keystone Health Plan West Matthew Thornton Health Plan, Inc. Mountain State
Blue Cross Blue Shield Premera Blue Cross Premera Blue Cross Blue Shield Premera
Blue Cross Blue Shield of Alaska QCC Insurance Company Regence BlueCross
BlueShield of Oregon Regence BlueCross BlueShield of Utah Regence BlueShield
Regence BlueShield of Idaho Regence Group Administrators Regence Health
Maintenance of Oregon Regence HMO Oregon Regence Life and Health Insurance
Company Regence ValueCare RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross
and Blue Shield Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem
Blue Cross and Blue Shield (of Colorado) Triple-S Management Corp. Triple-S
Salud, Inc. USAble Mutual Insurance Company Wellmark BCBS of Iowa Wellmark BCBS
of South Dakota Wellmark Health Plan of Iowa Wellmark Synergy Health Plan
Wellmark Value Health Plan Wisconsin Collaborative Insurance Company Other
Other Health Plan Name
Group #
Subscriber ID
Coverage Start Date
Coverage End Date
PAYMENT ELECTION
Please let us know how you would like to receive your settlement payment if your
claim is deemed valid.
Final determinations of claim amounts will not be made until after processing by
the Claims Administrator is complete. Claims will not be paid if the value is
equal to or less than $5.00.
Claimants who submit valid, approved claims shall receive a pro-rata percentage
of the Net Settlement Fund allocated to their type of coverage (fully-insured or
self-funded) based upon their estimated proportion of the cumulative total of
premiums and/or administrative fees paid by all claimants.
Payment Option Please Select Venmo PayPal Pre-paid Card Check
Venmo Username
PayPal Email
CONFIRMATION
Your claim form has been submitted successfully. Please keep the Claim Number
below for your records.
Claim Number:
SUPPORTING DOCUMENTATION
Print a Copy of Your Claim
REVIEW
Please review your claim information below. If you need to make any edits to
your claim, you may go back to a page by clicking that section of the progress
bar or clicking the Back button at the bottom of the page. If everything is
correct, complete the Signature section at the bottom of the page and click the
Submit button.
SUBSCRIBER INFORMATION
MAILING ADDRESS
--------------------------------------------------------------------------------
Street Line 1
Street Line 2
City
State
Zip
Province
Postal Code
Country
SUBSCRIBER NAME
--------------------------------------------------------------------------------
First Name
Middle Initial
Last Name
PHONE NUMBER
--------------------------------------------------------------------------------
Phone
Phone
EMAIL ADDRESS
--------------------------------------------------------------------------------
Email
HEALTH PLAN DETAILS
PAYMENT ELECTION
Payment Option
Venmo Username
PayPal Email
SIGNATURE
By checking this box, I affirm under the laws of the United States and the laws
of my State of residence that the information supplied in this Claim Form by the
undersigned is true and correct to the best of my recollection, and that this
form was executed on the date set forth below.
By checking this box, I understand that I may be asked to provide supplemental
information to the Claims Administrator and/or Settlement Administrator before
my claim will be considered complete and valid.
Type your name in the box below to electronically sign your claim
Date
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SUBSCRIBER INFORMATION
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City
State Alabama Alaska American Samoa Arizona Arkansas California Colorado
Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho
Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts
Michigan Minnesota Mississippi Missouri Northern Mariana Islands Montana
Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina
North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South
Carolina South Dakota Tennessee Texas Utah Vermont Virginia U.S. Virgin Islands
Washington West Virginia Wisconsin Wyoming AA AP AE
Province
Zip
Postal Code
Country Andorra Afghanistan Antigua and Barbuda Albania Armenia Angola Argentina
Austria Australia Azerbaijan Bosnia and Herzegovina Barbados Bangladesh Belgium
Burkina Faso Bulgaria Bahrain Burundi Benin Brunei Darussalam
Bolivia(Plurinational State of) Brazil Bahamas Bhutan Botswana Belarus Belize
Canada Central African Republic Congo Côte d'Ivoire Cape Verde Chile Cameroon
China Colombia Costa Rica Cuba Comoros Cyprus Czech Republic Germany Djibouti
Democratic Republic of the Congo Denmark Dominica Dominican Republic Algeria
Ecuador Estonia Egypt Eritrea Spain Ethiopia Finland Fiji Micronesia(Federated
States of) France Gabon Grenada Georgia Ghana Gambia Guinea Equatorial Guinea
Greece Guatemala Guinea-Bissau Guyana Honduras Croatia Haiti Hungary Indonesia
Ireland Israel India Iraq Iran(Islamic Republic of) Iceland Italy Jamaica Jordan
Japan Kenya Kyrgyzstan Cambodia Kiribati Saint Kitts and Nevis Democratic
People's Republic of Korea Republic of Korea Kuwait Kazakhstan Lao People's
Democratic Republic Lebanon Saint Lucia Liechtenstein Sri Lanka Liberia Lesotho
Lithuania Luxembourg Latvia Libyan Arab Jamahiriya Morocco Monaco Republic of
Moldova Montenegro Madagascar Marshall Islands The former Yugoslav Republic of
Macedonia Mali Myanmar Mongolia Mauritania Malta Mauritius Maldives Malawi
Mexico Malaysia Mozambique Namibia Niger Nigeria Nicaragua Netherlands Norway
Nepal Nauru New Zealand Oman Panama Peru Papua New Guinea Philippines Pakistan
Poland Portugal Palau Paraguay Qatar Romania Serbia Russian Federation Rwanda
Saudi Arabia Solomon Islands Seychelles Sudan Sweden Singapore Slovenia Slovakia
Sierra Leone San Marino Senegal Somalia Suriname South Africa South Sudan Sao
Tome and Principe El Salvador Syrian Arab Republic Eswatini Switzerland Chad
Togo Thailand Tajikistan Timor - Leste Turkmenistan Tunisia Tonga Turkey
Trinidad and Tobago Tuvalu Taiwan Ukraine Uganda United Arab Emirates United
Kingdom of Great Britain and Northern Ireland United Republic of Tanzania United
States of America Uruguay Uzbekistan Saint Vincent and the Grenadines
Venezuela(Bolivarian Republic of) Viet Nam Vanuatu Samoa Yemen Zambia Zimbabwe
Phone
Phone
Email
HEALTH PLAN DETAILS
Please do your best to provide as much information as you can below. While more
information will assist the Claims Administrator in processing your claim, only
boxes marked with an * are required.
1
EMPLOYEE HEALTH PLAN ENTRY
--------------------------------------------------------------------------------
Health Plan Name Anthem Blue Cross Life and Health Insurance Company Anthem
Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of
Kentucky) Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue
Shield (of Maine) Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue
Cross and Blue Shield (of New Hampshire) Anthem Health Plans of Virginia, Inc.
d/b/a Anthem Blue Cross and Blue Shield (of Virginia) Anthem Health Plans, Inc.
d/b/a Anthem Blue Cross and Blue Shield (of Connecticut) Anthem Insurance
Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana) Arkansas
Blue Cross and Blue Shield Blue Benefits Administrators Blue Care Network of
Michigan Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company
Blue Cross & Blue Shield of Rhode Island Blue Cross and Blue Shield of Alabama
Blue Cross and Blue Shield of Georgia, Inc. Blue Cross and Blue Shield of
Illinois Blue Cross and Blue Shield of Kansas Blue Cross and Blue Shield of
Kansas City Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Blue
Cross and Blue Shield of Massachusetts, Inc. Blue Cross and Blue Shield of
Minnesota Blue Cross and Blue Shield of Montana Blue Cross and Blue Shield of
New Mexico Blue Cross and Blue Shield of North Carolina Blue Cross and Blue
Shield of Oklahoma Blue Cross and Blue Shield of Texas Blue Cross and Blue
Shield of Vermont Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a
Anthem Blue Cross and Blue Shield Blue Cross Blue Shield of Delaware Blue Cross
Blue Shield of Louisiana Blue Cross Blue Shield of Massachusetts Blue Cross Blue
Shield of Michigan Blue Cross Blue Shield of Nebraska Blue Cross Blue Shield of
North Dakota Blue Cross Blue Shield of Northeastern Pennsylvania Blue Cross Blue
Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield Blue Cross Blue
Shield of Wyoming Blue Cross of California d/b/a Anthem Blue Cross Blue Cross of
Idaho Blue Plus Blue Shield of California Blue Shield of California Life &
Health Insurance Company BlueAdvantage Administrators of Arkansas BlueChoice
HealthPlan of South Carolina BlueCross BlueShield of Arizona BlueCross
BlueShield of Florida, Inc. BlueCross BlueShield of South Carolina BlueCross
BlueShield of Tennessee BlueCross BlueShield of Western New York BlueShield of
Northeastern New York California Physicians’ Service dba Blue Shield of
California Capital Advantage Assurance Company (CAAC) Capital Advantage
Insurance Company (CAIC) Capital BlueCross Capital Health Plan, Inc. CareFirst
BlueChoice, Inc. CareFirst BlueCross BlueShield DC/Montgomery County/Prince
George’s County/Virginia CareFirst BlueCross BlueShield Maryland CareFirst of
Maryland, Inc. (CFMI) CBA Blue (Vermont) CFA LLC Claim Management Services, Inc.
d/b/a Anthem Blue Cross and Blue Shield Community Insurance Company d/b/a Anthem
Blue Cross and Blue Shield (of Ohio) Compcare Health Services Insurance
Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of Wisconsin) Empire
HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield Empire
HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield Excellus BlueCross
BlueShield First Priority Health First Priority Life Florida Blue Florida Health
Care Plan, Inc. Group Hospitalization and Medical Services, Inc. (GHMSI) Hawaii
Medical Service Association (HMSA) Health Advantage HealthKeepers, Inc.
Healthwise Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and
Blue Shield (of Missouri) Highmark Blue Cross Blue Shield Highmark Blue Cross
Blue Shield of Delaware Highmark Blue Cross Blue Shield of West Virginia
Highmark Blue Shield HMO Colorado, Inc. HMO Colorado, Inc. d/b/a HMO Nevada,
Inc. HMO Louisiana, Inc. HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue
Shield (of Missouri) HMO Partners, Inc. Horizon Blue Cross Blue Shield of New
Jersey Independence Administrators Independence Blue Cross Independence Hospital
Indemnity Plan Keystone Health Plan Central, Inc. (KHPC) Keystone Health Plan
East Keystone Health Plan West Matthew Thornton Health Plan, Inc. Mountain State
Blue Cross Blue Shield Premera Blue Cross Premera Blue Cross Blue Shield Premera
Blue Cross Blue Shield of Alaska QCC Insurance Company Regence BlueCross
BlueShield of Oregon Regence BlueCross BlueShield of Utah Regence BlueShield
Regence BlueShield of Idaho Regence Group Administrators Regence Health
Maintenance of Oregon Regence HMO Oregon Regence Life and Health Insurance
Company Regence ValueCare RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross
and Blue Shield Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem
Blue Cross and Blue Shield (of Colorado) Triple-S Management Corp. Triple-S
Salud, Inc. USAble Mutual Insurance Company Wellmark BCBS of Iowa Wellmark BCBS
of South Dakota Wellmark Health Plan of Iowa Wellmark Synergy Health Plan
Wellmark Value Health Plan Wisconsin Collaborative Insurance Company Other
Other Health Plan Name
Group #
Employer Name
Employer Address
Subscriber or Member ID
Coverage Start Date
Coverage End Date
2
INDIVIDUAL HEALTH PLAN ENTRY
--------------------------------------------------------------------------------
Health Plan Name Anthem Blue Cross Life and Health Insurance Company Anthem
Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of
Kentucky) Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue
Shield (of Maine) Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue
Cross and Blue Shield (of New Hampshire) Anthem Health Plans of Virginia, Inc.
d/b/a Anthem Blue Cross and Blue Shield (of Virginia) Anthem Health Plans, Inc.
d/b/a Anthem Blue Cross and Blue Shield (of Connecticut) Anthem Insurance
Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana) Arkansas
Blue Cross and Blue Shield Blue Benefits Administrators Blue Care Network of
Michigan Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company
Blue Cross & Blue Shield of Rhode Island Blue Cross and Blue Shield of Alabama
Blue Cross and Blue Shield of Georgia, Inc. Blue Cross and Blue Shield of
Illinois Blue Cross and Blue Shield of Kansas Blue Cross and Blue Shield of
Kansas City Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Blue
Cross and Blue Shield of Massachusetts, Inc. Blue Cross and Blue Shield of
Minnesota Blue Cross and Blue Shield of Montana Blue Cross and Blue Shield of
New Mexico Blue Cross and Blue Shield of North Carolina Blue Cross and Blue
Shield of Oklahoma Blue Cross and Blue Shield of Texas Blue Cross and Blue
Shield of Vermont Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a
Anthem Blue Cross and Blue Shield Blue Cross Blue Shield of Delaware Blue Cross
Blue Shield of Louisiana Blue Cross Blue Shield of Massachusetts Blue Cross Blue
Shield of Michigan Blue Cross Blue Shield of Nebraska Blue Cross Blue Shield of
North Dakota Blue Cross Blue Shield of Northeastern Pennsylvania Blue Cross Blue
Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield Blue Cross Blue
Shield of Wyoming Blue Cross of California d/b/a Anthem Blue Cross Blue Cross of
Idaho Blue Plus Blue Shield of California Blue Shield of California Life &
Health Insurance Company BlueAdvantage Administrators of Arkansas BlueChoice
HealthPlan of South Carolina BlueCross BlueShield of Arizona BlueCross
BlueShield of Florida, Inc. BlueCross BlueShield of South Carolina BlueCross
BlueShield of Tennessee BlueCross BlueShield of Western New York BlueShield of
Northeastern New York California Physicians’ Service dba Blue Shield of
California Capital Advantage Assurance Company (CAAC) Capital Advantage
Insurance Company (CAIC) Capital BlueCross Capital Health Plan, Inc. CareFirst
BlueChoice, Inc. CareFirst BlueCross BlueShield DC/Montgomery County/Prince
George’s County/Virginia CareFirst BlueCross BlueShield Maryland CareFirst of
Maryland, Inc. (CFMI) CBA Blue (Vermont) CFA LLC Claim Management Services, Inc.
d/b/a Anthem Blue Cross and Blue Shield Community Insurance Company d/b/a Anthem
Blue Cross and Blue Shield (of Ohio) Compcare Health Services Insurance
Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of Wisconsin) Empire
HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield Empire
HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield Excellus BlueCross
BlueShield First Priority Health First Priority Life Florida Blue Florida Health
Care Plan, Inc. Group Hospitalization and Medical Services, Inc. (GHMSI) Hawaii
Medical Service Association (HMSA) Health Advantage HealthKeepers, Inc.
Healthwise Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and
Blue Shield (of Missouri) Highmark Blue Cross Blue Shield Highmark Blue Cross
Blue Shield of Delaware Highmark Blue Cross Blue Shield of West Virginia
Highmark Blue Shield HMO Colorado, Inc. HMO Colorado, Inc. d/b/a HMO Nevada,
Inc. HMO Louisiana, Inc. HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue
Shield (of Missouri) HMO Partners, Inc. Horizon Blue Cross Blue Shield of New
Jersey Independence Administrators Independence Blue Cross Independence Hospital
Indemnity Plan Keystone Health Plan Central, Inc. (KHPC) Keystone Health Plan
East Keystone Health Plan West Matthew Thornton Health Plan, Inc. Mountain State
Blue Cross Blue Shield Premera Blue Cross Premera Blue Cross Blue Shield Premera
Blue Cross Blue Shield of Alaska QCC Insurance Company Regence BlueCross
BlueShield of Oregon Regence BlueCross BlueShield of Utah Regence BlueShield
Regence BlueShield of Idaho Regence Group Administrators Regence Health
Maintenance of Oregon Regence HMO Oregon Regence Life and Health Insurance
Company Regence ValueCare RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross
and Blue Shield Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem
Blue Cross and Blue Shield (of Colorado) Triple-S Management Corp. Triple-S
Salud, Inc. USAble Mutual Insurance Company Wellmark BCBS of Iowa Wellmark BCBS
of South Dakota Wellmark Health Plan of Iowa Wellmark Synergy Health Plan
Wellmark Value Health Plan Wisconsin Collaborative Insurance Company Other
Other Health Plan Name
Group #
Subscriber ID
Coverage Start Date
Coverage End Date
--------------------------------------------------------------------------------
Group # field is required.
LocKey_CoverageStartDateRequiredErrMsgRequiredErrMsg
LocKey_CoverageEndDateRequiredErrMsgRequiredErrMsg
Add Employee Health Plan
Add Individual Health Plan
HEALTH PLAN ENTRY
Delete Entry
--------------------------------------------------------------------------------
Health Plan Name Anthem Blue Cross Life and Health Insurance Company Anthem
Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of
Kentucky) Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue
Shield (of Maine) Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue
Cross and Blue Shield (of New Hampshire) Anthem Health Plans of Virginia, Inc.
d/b/a Anthem Blue Cross and Blue Shield (of Virginia) Anthem Health Plans, Inc.
d/b/a Anthem Blue Cross and Blue Shield (of Connecticut) Anthem Insurance
Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana) Arkansas
Blue Cross and Blue Shield Blue Benefits Administrators Blue Care Network of
Michigan Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company
Blue Cross & Blue Shield of Rhode Island Blue Cross and Blue Shield of Alabama
Blue Cross and Blue Shield of Georgia, Inc. Blue Cross and Blue Shield of
Illinois Blue Cross and Blue Shield of Kansas Blue Cross and Blue Shield of
Kansas City Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Blue
Cross and Blue Shield of Massachusetts, Inc. Blue Cross and Blue Shield of
Minnesota Blue Cross and Blue Shield of Montana Blue Cross and Blue Shield of
New Mexico Blue Cross and Blue Shield of North Carolina Blue Cross and Blue
Shield of Oklahoma Blue Cross and Blue Shield of Texas Blue Cross and Blue
Shield of Vermont Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a
Anthem Blue Cross and Blue Shield Blue Cross Blue Shield of Delaware Blue Cross
Blue Shield of Louisiana Blue Cross Blue Shield of Massachusetts Blue Cross Blue
Shield of Michigan Blue Cross Blue Shield of Nebraska Blue Cross Blue Shield of
North Dakota Blue Cross Blue Shield of Northeastern Pennsylvania Blue Cross Blue
Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield Blue Cross Blue
Shield of Wyoming Blue Cross of California d/b/a Anthem Blue Cross Blue Cross of
Idaho Blue Plus Blue Shield of California Blue Shield of California Life &
Health Insurance Company BlueAdvantage Administrators of Arkansas BlueChoice
HealthPlan of South Carolina BlueCross BlueShield of Arizona BlueCross
BlueShield of Florida, Inc. BlueCross BlueShield of South Carolina BlueCross
BlueShield of Tennessee BlueCross BlueShield of Western New York BlueShield of
Northeastern New York California Physicians’ Service dba Blue Shield of
California Capital Advantage Assurance Company (CAAC) Capital Advantage
Insurance Company (CAIC) Capital BlueCross Capital Health Plan, Inc. CareFirst
BlueChoice, Inc. CareFirst BlueCross BlueShield DC/Montgomery County/Prince
George’s County/Virginia CareFirst BlueCross BlueShield Maryland CareFirst of
Maryland, Inc. (CFMI) CBA Blue (Vermont) CFA LLC Claim Management Services, Inc.
d/b/a Anthem Blue Cross and Blue Shield Community Insurance Company d/b/a Anthem
Blue Cross and Blue Shield (of Ohio) Compcare Health Services Insurance
Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of Wisconsin) Empire
HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield Empire
HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield Excellus BlueCross
BlueShield First Priority Health First Priority Life Florida Blue Florida Health
Care Plan, Inc. Group Hospitalization and Medical Services, Inc. (GHMSI) Hawaii
Medical Service Association (HMSA) Health Advantage HealthKeepers, Inc.
Healthwise Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and
Blue Shield (of Missouri) Highmark Blue Cross Blue Shield Highmark Blue Cross
Blue Shield of Delaware Highmark Blue Cross Blue Shield of West Virginia
Highmark Blue Shield HMO Colorado, Inc. HMO Colorado, Inc. d/b/a HMO Nevada,
Inc. HMO Louisiana, Inc. HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue
Shield (of Missouri) HMO Partners, Inc. Horizon Blue Cross Blue Shield of New
Jersey Independence Administrators Independence Blue Cross Independence Hospital
Indemnity Plan Keystone Health Plan Central, Inc. (KHPC) Keystone Health Plan
East Keystone Health Plan West Matthew Thornton Health Plan, Inc. Mountain State
Blue Cross Blue Shield Premera Blue Cross Premera Blue Cross Blue Shield Premera
Blue Cross Blue Shield of Alaska QCC Insurance Company Regence BlueCross
BlueShield of Oregon Regence BlueCross BlueShield of Utah Regence BlueShield
Regence BlueShield of Idaho Regence Group Administrators Regence Health
Maintenance of Oregon Regence HMO Oregon Regence Life and Health Insurance
Company Regence ValueCare RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross
and Blue Shield Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem
Blue Cross and Blue Shield (of Colorado) Triple-S Management Corp. Triple-S
Salud, Inc. USAble Mutual Insurance Company Wellmark BCBS of Iowa Wellmark BCBS
of South Dakota Wellmark Health Plan of Iowa Wellmark Synergy Health Plan
Wellmark Value Health Plan Wisconsin Collaborative Insurance Company Other
Other Health Plan Name
Group #
Employer Name
Employer Address
Subscriber or Member ID
Coverage Start Date
Coverage End Date
HEALTH PLAN ENTRY
Delete Entry
--------------------------------------------------------------------------------
Health Plan Name Anthem Blue Cross Life and Health Insurance Company Anthem
Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield (of
Kentucky) Anthem Health Plans of Maine, Inc. d/b/a Anthem Blue Cross and Blue
Shield (of Maine) Anthem Health Plans of New Hampshire, Inc. d/b/a Anthem Blue
Cross and Blue Shield (of New Hampshire) Anthem Health Plans of Virginia, Inc.
d/b/a Anthem Blue Cross and Blue Shield (of Virginia) Anthem Health Plans, Inc.
d/b/a Anthem Blue Cross and Blue Shield (of Connecticut) Anthem Insurance
Companies, Inc. d/b/a Anthem Blue Cross and Blue Shield (of Indiana) Arkansas
Blue Cross and Blue Shield Blue Benefits Administrators Blue Care Network of
Michigan Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company
Blue Cross & Blue Shield of Rhode Island Blue Cross and Blue Shield of Alabama
Blue Cross and Blue Shield of Georgia, Inc. Blue Cross and Blue Shield of
Illinois Blue Cross and Blue Shield of Kansas Blue Cross and Blue Shield of
Kansas City Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Blue
Cross and Blue Shield of Massachusetts, Inc. Blue Cross and Blue Shield of
Minnesota Blue Cross and Blue Shield of Montana Blue Cross and Blue Shield of
New Mexico Blue Cross and Blue Shield of North Carolina Blue Cross and Blue
Shield of Oklahoma Blue Cross and Blue Shield of Texas Blue Cross and Blue
Shield of Vermont Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a
Anthem Blue Cross and Blue Shield Blue Cross Blue Shield of Delaware Blue Cross
Blue Shield of Louisiana Blue Cross Blue Shield of Massachusetts Blue Cross Blue
Shield of Michigan Blue Cross Blue Shield of Nebraska Blue Cross Blue Shield of
North Dakota Blue Cross Blue Shield of Northeastern Pennsylvania Blue Cross Blue
Shield of Wisconsin d/b/a Anthem Blue Cross and Blue Shield Blue Cross Blue
Shield of Wyoming Blue Cross of California d/b/a Anthem Blue Cross Blue Cross of
Idaho Blue Plus Blue Shield of California Blue Shield of California Life &
Health Insurance Company BlueAdvantage Administrators of Arkansas BlueChoice
HealthPlan of South Carolina BlueCross BlueShield of Arizona BlueCross
BlueShield of Florida, Inc. BlueCross BlueShield of South Carolina BlueCross
BlueShield of Tennessee BlueCross BlueShield of Western New York BlueShield of
Northeastern New York California Physicians’ Service dba Blue Shield of
California Capital Advantage Assurance Company (CAAC) Capital Advantage
Insurance Company (CAIC) Capital BlueCross Capital Health Plan, Inc. CareFirst
BlueChoice, Inc. CareFirst BlueCross BlueShield DC/Montgomery County/Prince
George’s County/Virginia CareFirst BlueCross BlueShield Maryland CareFirst of
Maryland, Inc. (CFMI) CBA Blue (Vermont) CFA LLC Claim Management Services, Inc.
d/b/a Anthem Blue Cross and Blue Shield Community Insurance Company d/b/a Anthem
Blue Cross and Blue Shield (of Ohio) Compcare Health Services Insurance
Corporation d/b/a d/b/a Anthem Blue Cross and Blue Shield (of Wisconsin) Empire
HealthChoice Assurance, Inc. d/b/a Empire BlueCross BlueShield Empire
HealthChoice HMO, Inc. d/b/a Empire BlueCross BlueShield Excellus BlueCross
BlueShield First Priority Health First Priority Life Florida Blue Florida Health
Care Plan, Inc. Group Hospitalization and Medical Services, Inc. (GHMSI) Hawaii
Medical Service Association (HMSA) Health Advantage HealthKeepers, Inc.
Healthwise Healthy Alliance Life Insurance Company d/b/a Anthem Blue Cross and
Blue Shield (of Missouri) Highmark Blue Cross Blue Shield Highmark Blue Cross
Blue Shield of Delaware Highmark Blue Cross Blue Shield of West Virginia
Highmark Blue Shield HMO Colorado, Inc. HMO Colorado, Inc. d/b/a HMO Nevada,
Inc. HMO Louisiana, Inc. HMO Missouri, Inc. d/b/a Anthem Blue Cross and Blue
Shield (of Missouri) HMO Partners, Inc. Horizon Blue Cross Blue Shield of New
Jersey Independence Administrators Independence Blue Cross Independence Hospital
Indemnity Plan Keystone Health Plan Central, Inc. (KHPC) Keystone Health Plan
East Keystone Health Plan West Matthew Thornton Health Plan, Inc. Mountain State
Blue Cross Blue Shield Premera Blue Cross Premera Blue Cross Blue Shield Premera
Blue Cross Blue Shield of Alaska QCC Insurance Company Regence BlueCross
BlueShield of Oregon Regence BlueCross BlueShield of Utah Regence BlueShield
Regence BlueShield of Idaho Regence Group Administrators Regence Health
Maintenance of Oregon Regence HMO Oregon Regence Life and Health Insurance
Company Regence ValueCare RightCHOICE Managed Care, Inc. d/b/a Anthem Blue Cross
and Blue Shield Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem
Blue Cross and Blue Shield (of Colorado) Triple-S Management Corp. Triple-S
Salud, Inc. USAble Mutual Insurance Company Wellmark BCBS of Iowa Wellmark BCBS
of South Dakota Wellmark Health Plan of Iowa Wellmark Synergy Health Plan
Wellmark Value Health Plan Wisconsin Collaborative Insurance Company Other
Other Health Plan Name
Group #
Subscriber ID
Coverage Start Date
Coverage End Date
ALLOCATION OF PREMIUMS
The Settlement provides that payments will be based, in part, on premiums paid
for BCBS health insurance or administrative services plans during the relevant
periods between February 2008 and October 2020 for fully insured plans, and
between September 2015 and October 2020 for administrative services plans.
The Settlement further provides default formulas for the Claims Administrator to
use when determining what percentage of the premium was paid by an
employer/entity and what percentage was contributed by its employees/members.
If you accept the Default option , you are NOT required to provide any
additional data or evidence in support of your claim at this time. If another
claimant’s filing affects your claim, you will be provided with an opportunity
to respond at a later date.
If you proceed with the Alternative option , you must also provide data or
evidence to support the alternative contribution percentages you provide. If you
select this option, for any time period for which supporting data or evidence is
not provided, the Default Option will be applied.
ACCEPT THE DEFAULT OPTION
APPLY FOR AN ALTERNATIVE CONTRIBUTION %
STOP: If you want to use the DEFAULT OPTION, DO NOT FILL OUT THIS SECTION.
Instead, click HERE.
1
ALTERNATIVE OPTION
--------------------------------------------------------------------------------
Please state the percentage contribution you believe you contributed for each
year that you were enrolled in a BCBS health insurance or administrative
services plan.
Plan Year
Contribution
--------------------------------------------------------------------------------
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
%
ADD ANOTHER YEAR
2
UPLOAD SUPPORTING DOCUMENTATION
--------------------------------------------------------------------------------
If you choose to apply for an alternative contribution percentage you must
supply documentation with this claim form supporting the percentage you claim to
have contributed. If you do not submit supporting documentation the Default
contribution rates will be applied to your claim.
Check this box if you want to upload your documents later.
Supported files include: .jpg, .jpeg, .pdf, .png, .tif, and .tiff. Maximum
upload size is 10MB
DELETE FILE
ADD ANOTHER FILE
ALTERNATIVE CONTRIBUTION
×
If you choose to apply for an alternative contribution percentage, you must
supply documentation with this claim form supporting the percentage you claim to
have contributed. If you do not provide additional documentation, the Default
Option will be applied to your claim.
Selection of the Alternative Option does not ensure a contribution percentage
higher than or equal to the Default Option. Your percentage will be dependent on
a process that includes a review of all materials submitted pertaining to your
premium.
Are you sure you want to apply for an alternative contribution percentage?
Continue with alternative option
Switch to the default option
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
%
Delete Entry
DELETE FILE
PAYMENT ELECTION
Please let us know how you would like to receive your settlement payment if your
claim is deemed valid.
Final determinations of claim amounts will not be made until after processing by
the Claims Administrator is complete. Claims will not be paid if the value is
equal to or less than $5.00.
Claimants who submit valid, approved claims shall receive a pro-rata percentage
of the Net Settlement Fund allocated to their type of coverage (fully-insured or
self-funded) based upon their estimated proportion of the cumulative total of
premiums and/or administrative fees paid by all claimants.
Payment Option Please Select Venmo PayPal Pre-paid Card Check
Venmo Username
PayPal Email
CONFIRMATION
Your claim form has been submitted successfully. Please keep the Claim Number
below for your records.
Claim Number:
SUPPORTING DOCUMENTATION
Print a Copy of Your Claim
REVIEW
Please review your claim information below. If you need to make any edits to
your claim, you may go back to a page by clicking that section of the progress
bar or clicking the Back button at the bottom of the page. If everything is
correct, complete the Signature section at the bottom of the page and click the
Submit button.
SUBSCRIBER INFORMATION
MAILING ADDRESS
--------------------------------------------------------------------------------
Street Line 1
Street Line 2
City
State
Zip
Province
Postal Code
Country
SUBSCRIBER NAME
--------------------------------------------------------------------------------
First Name
Middle Initial
Last Name
PHONE NUMBER
--------------------------------------------------------------------------------
Phone
Phone
EMAIL ADDRESS
--------------------------------------------------------------------------------
Email
HEALTH PLAN DETAILS
ALLOCATION OF PREMIUMS
ALTERNATIVE CONTRIBUTION % SELECTED
DEFAULT OPTION SELECTED
ALTERNATIVE OPTION
--------------------------------------------------------------------------------
Plan Year
Contribution
--------------------------------------------------------------------------------
UPLOAD SUPPORTING DOCUMENTATION
--------------------------------------------------------------------------------
Please Wait For Upload
Upload Failed For Files
PAYMENT ELECTION
Payment Option
Venmo Username
PayPal Email
SIGNATURE
By checking this box, I affirm under the laws of the United States and the laws
of my State of residence that the information supplied in this Claim Form by the
undersigned is true and correct to the best of my recollection, and that this
form was executed on the date set forth below.
By checking this box, I understand that I may be asked to provide supplemental
information to the Claims Administrator and/or Settlement Administrator before
my claim will be considered complete and valid.
Type your name in the box below to electronically sign your claim
Date
--------------------------------------------------------------------------------
Health Plan Name
Group #
Coverage Start Date
Coverage End Date
Employer Name
Employer Address
Subscriber or Member ID
--------------------------------------------------------------------------------
Health Plan Name
Group #
Subscriber ID
Coverage Start Date
Coverage End Date
%
ERROR
Your Claim Form Has Not Been Submitted
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