- Current Step 1) Tell us about yourself
- Step 2) Tell us about your household
- Step 3) Choose a plan and payment
- Step 4) Tell us if you have other dental and/or vision insurance
- Step 5) Review notification and authorization information
- Step 6) Review payment and billing information
- Step 7) Sign the Application
- Step 8) Agent Attestation
- Complete
 
 

To purchase an individual and family [dental](/our-plans/individual-family-health-plans/individuals-and-families-dental-plans "Individuals and families dental plans") or [vision](/our-plans/individual-family-health-plans/individuals-and-families-vision-plans "Individuals and families vision plans") plan complete the enrollment form below and provide all required documents. You must be a Minnesota resident over the age of 18 or have a parent or guardian listed as a contract holder to enroll in a plan.

For help completing the enrollment form call **1-800-531-6685** (TTY **771**) or schedule an appointment with a [Blue Cross Advisor](/our-plans/blue-cross-advisors "Blue Cross Advisors").

 

 I have an existing Blue Cross/Blue Plus® member ID number  

 Choose an applicant type - Select -I am a new applicantI am currently enrolled in a Blue Cross Dental or Vision individual plan 

  I am a new applicant   Applying for coverage for myself only  

  Applying for coverage for myself and my dependents 



 

  I am currently enrolled in a Blue Cross Dental or Vision individual plan   Adding a dependent 

  Making a plan change 



 

**Please note:** Processing of your Application may be delayed if this form is not completed in its entirety.

 

When you include Social Security numbers (SSNs), we can process your Application more efficiently, but you are not required to include them for your dependents or yourself.

 

 First Name  

 Last Name and Suffix  

 Social Security Number (optional)  

  Gender   Male 

  Female 



 

 Date of Birth  

 Permanent Home Address (No P.O. Box #)  

 City  

 State  

 ZIP  

 County  

  Correspondence Address (If different from home address) 

 Correspondence Address  

 City  

 State  

 ZIP  

 County  

  Billing Address (If different from permanent home and correspondence address) 

 Billing Address  

 City  

 State  

 ZIP  

 County  

 E-mail address  

 Primary Phone Number  

  I have been a permanent resident of Minnesota for a minimum of 183 days?   Yes 

  No 



 

  Will you or any other enrollee receive any premium or cost-sharing payments made by a specific person or entity, directly or indirectly, by any ineligible third party??   Yes 

  No 



 

  Ethnic Background?   Non-Hispanic or Latino 

  Hispanic or Latino 

  Choose not to answer 



 

  Race   Black or African American 

  Native Hawaiian/Other Pacific Islander 

  White 

  Asian 

  American Indian or Alaskan Native 

  Other, please specify 

  Choose not to answer 

 

 Please specify  

  Spoken Language?   English 

  Spanish 

  Other, please specify 

  Choose not to answer 



 

 Please specify  

  Written Language?   English 

  Spanish 

  Other, please specify 

  Choose not to answer 



 

 Please specify  

  Ethnic background and race is the same for all dependents. If checked, ethnic background and race do not need to be selected for dependent(s) within the following section.