BlueCross BlueShield of Tennessee Intake Form

Once the new business form is received, Pinnacle will contact the Primary Contact to begin the onboarding process and determine next steps. We appreciate the opportunity to serve you and your client.

Company Information

Company Name *

Tax ID *

Street Address *

City *

State *

Zip *

Contact Information

Primary Contact Name *

Email Address *

Phone Number (with area code) *

Onboarding Call Information

Contact Name

Contact Email Address

Contact Phone Number (with area code)

Plan Information

Number of benefit-eligible employees

Effective date of plan

Health insurance carrier for new plan year

Additional Information

Are you working with a broker or consultant?

Yes

Broker or Consultant Name

Do you have a BCBSTN group number?

Yes

What is the group number?

Products

Products to be administered by Pinnacle *

Health Savings Accounts
Flexible Spending Accounts
Health Reimbursement Arrangements

Submitted by: *