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Download the COVID-19 (Coronavirus) Resource Guide (as of June 28, 2021), created especially for our valued customers.

Enroll / Elect / Apply

PDF  2022 Group Application (Midsize & Public Sector)

Use this form to implement a new business group with a Horizon Medical and/or Ancillary Plan in the 51+ and Public Sector markets. ID: 40079 (0721)

PDF  Enrollment Change/Request form Medical/Dental/Vision (Small Groups)

Use this form to enroll a new subscriber, or make a change to a current enrollment, to a Horizon BCBSNJ Medical, Dental, or Vision plan for small groups. ID: 6803

PDF  Enrollment/Change Request Form - Medical and Dental (Mid-Size and Large Groups)

Use this form to enroll a new subscriber, or make a change to a current enrollment, to a Horizon BCBSNJ Medical or Dental plan for mid-size and large groups. ID: 6859

PDF  Enrollment/Change Request Form – English (Individuals-Families) - 2018

ID: 744 With Peds (W1017)

PDF  Enrollment/Change Request Form – Spanish (Individuals-Families) - 2018

ID: 744 con peds (W1017)

PDF  Medicare Advantage and Part D Group Enrollment Form

ID: HORAP093

PDF  Medicare Group Employer Application Form

ID: Y0090

PDF  Medicare Prescription Drug Plan Group Enrollment Form

ID: HORAP094

PDF  Request Form - Medical - Continuance of Enrollment for Disabled Dependent (Groups 2-50)

Members with a mentally-impaired or physically-disabled child can use this form to request that the child be covered by the parent’s medical plan. ID: 2407