Are you filing for a business or are you filing for yourself ?

Business

Myself

Business Information

Please provide the following information:
1
Full Name of Company

2
Primary Headquarters Mailing Address

3
Current Company Contact (Name and Title)

4
Office Phone Number

5
Company Contact 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


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 %

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.

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

Primary Headquarters Mailing Address

Current Company Contact (Name and Title)

Office Phone Number

Company Contact Email Address

Health Plan Details

Allocation of Premiums

Payment Election

Signature

Subscriber Information

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


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 %

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.

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

Subscriber Name

Phone Number

Email Address

Health Plan Details

Allocation of Premiums

Payment Election

Signature

Subscriber Information

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


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.

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

Subscriber Name

Phone Number

Email Address

Health Plan Details

Payment Election

Signature

Subscriber Information

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

2
Individual Health Plan Entry


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 %

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.

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

Subscriber Name

Phone Number

Email Address

Health Plan Details

Allocation of Premiums

Payment Election

Signature