CHANCE! Luna Insurance Agency

~ Health, Life, Dental & Vision, Legal Insurance~
Individual & Group Specialists

BCBS ENROLLMENT MOLINA

Enrollment-- FREE

BLUE CROSS BLUE SHIELD

HEALTH INSURANCE

SUBMIT FORM BELOW

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Drop us a message! We'd love to hear from you!

Questions-Comments-Ready to Sign Up!

Please fill out the form and we'll get back to you as soon as we can.

or call 214.675.0999 anytime 24/7 to speak w one of CHANCES! Agents. or ASK for Chance and he will personally handle your questions and even your account and insurance needs.

Simple ONLINE enrollment for FREE Blue Cross Blue Shield Health Insurance. Sign you and your family up today to have quality coverage you deserve at NO COST monthly.

FREE HEALTH INSURANCE!

SIMPLE ONLINE ENROLLMENT!

* all prices and plans may change at any time. PLEASE KNOW THAT CHANCE! Luna Ins Agency WILL NOT PROCESS AN APPLICATION THAT HAS NOT COMPLETED IDENTITY VERIFICATION. Any person applying for coverage for someone other than whom they have purpose of insuring WILL NOT BE APPROVED and ARE SUBJECT TO PROSECUTION.

Complete the following to Enroll in Free Healthcare w BCBSTx / Agree by selecting YES in next box
BCBSTX Plan Selection
- $0 MONTHLY/$50 DED $900 OOP / $5 DR COPAY (2 PER YEAR) --------Rx $0 GENERIC / 30% BRAND
- $26 MONTHLY/$125 DED $750 OOP / $5 DR COPAY (UNLIMITED)----------Rx $5 GENERIC / 30% BRAND
YOUR NAME
HOME ADDRESS
PHONE NUMBER
DOB
# S S
MARRIED
SPOUSE
SPOUSE DOB
SPOUSE SS#
CHILDREN
CHILD 1 NAME
CHILD 1 DOB
CHILD 1 SS#
CHILD 2 NAME
CHILD 2 DOB
CHILD 2 SS#
HOUSEHOLD INCOME FOR YEAR 2019 AFTER TAXES DEDUCTIONS AND EXPENSES INCLUDING ALL FAMILY MEMBERS
EMPLOYER NAME (They will not be contacted) If SELF EMPLOYED type SELF and nature of job/ tasks ie child care, contractor, housekeeper/maid/personal assistant, dogwalker etc
APP AGREEMENT -PLEASE TYPE YOUR FULL NAME AND AGREE AND HAVE THE CONSENT OF ALL APPLYING
DATE
Select YES to allow CHANCE! Luna Insurance Agency to act on your behalf throughout the application process. Allowing CLIA permission to set up maintain and when needed service the account to keep plan benefits in effect. CLIA will never have any access to any medical records or claims history.
S S # NUMBERS WILL BE NEEDED TO VALIDATE THE MEMBER-- YOU MAY LEAVE BLANK AND OPT TO HAVE AN AGENT CALL OR EMAIL YOU TO GET THIS INFO IF YOU DONT ENTER ABOVE
Your Email Address
ADDITIONAL INFO-ADDITIONAL CHILDREN- PREVIOUS COVERAGE- INTEREST IN DENTAL PLEASE ADD QUESTIONS AND CONCERNS
Submit

Thank you for your enrollment in the Blue Cross Blue Shield Health Plan. Chance Luna or one of his trusted associates will be contacting you welcoming you as well finalizing any questions needed or incomplete info.

Don't forget to get your Friends & Family signed up as well.

Especially anyone you know is sick! Sign them up first! Be the hero! Pay zero! ...a month for health insurance. ~ Fancy Chance

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