850.747.0288 admin@bayinspc.com

 

INSURING LIVES. ENRICHING FUTURES.

 

 

Insurance Provider Forms

Please see the insurance forms below.

 


 

Blue Cross Blue Shield of Florida

 

Authorization Form

Authorization to release "Protected Health Information"

Employee Application

Blue Cross Blue Shield Health and Financial Enrollment Application

Major Medical Claim Form

For submitting claims for services and supplies that are not submitted by your provider.

Prescription Drug Claim Form

Prescription Drug Program Subscriber Claim Form

PrimeMail Order Form

New Prescription PrimeMail Order Form for Blue Cross Blue Shield of Florida

Medicare PrimeMail Order Form

New Prescription PrimeMail Order Form for Medicare

 


 

Guardian Insurance

 

Guardian Enrollment Form

Enrollment Application for Guardian Insurance

 


 

Metlife Insurance

 

Metlife Enrollment Form

Enrollment for Group Insurance

Metlife Change Request Form

Name Change, Address Change, Add Dependant

 


 

Ohio National Insurance

 

Ohio National Beneficiary Information Sheet

Add a Beneficiary to your Insurance Policy

Ohio National Beneficiary Change Request Form

This form offers the ability to make changes on your policy plan

 


 

United Concordia Dental

 

United Concorida Form

Enrollment Application Form

 

 

 

Request A FREE Quote

 

     

 

 

Contact Info

 

Nichols & Associates of Bay County, Inc.

1229 Jenks Avenue

Panama City, Florida 32401

 

Phone 850.747.0288

Fax 850.747.1464

 

admin@bayinspc.com

 

 

 

Insuring Lives. Enriching Futures.

 

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