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BLUE CROSS
APPLICATION 65 EXTENDED Husband and wife must file separate applications BLUE SHIELD PLEASE PRINT PLEASE PRINT I wish to enroll as a Subscriber for the prepaid health care services offered by Virginia Hospital, Service Association and Virginia Medical Service Association under the 65 Extended Contract. My Social Security Number _
Birth Month-Year_ □ Male □ Female Name: □ Miss □ Mrs. □ Mr.____ (first name) (middle Initial) (last name) Address:___ ZIP Code
Please bill me for this coverage every □ 2, Q 6. or Q 12 months Are you now a Blue Cross member? DYES □ NO Blue Cross Plan of _ under Contract Number If Blue Cross group coverage, . give group's name and address: (city or state) Do you have □ Spouse under 65 □ Unmarried dependent children under 19 - CHECK ONE □ I do not have other health □ I have other health care care coverage except that coverage to. supplement the provided by the Federal Federal Medicare program with: Medicare program. (nama of insurance company) I certify that the information on this application is accurate to the best of my knowledge. Form E-100-5 (45) Date Applicant’s Signature _
BLUE CROSS-BLUE SHIELD, «m Street, Frederldubarg, Va. mil
72.9%