Group Activity Report (GAR) Form

Use this form to add new dependents to an existing policy, cancel coverage, change plan benefits elections, or transfer subscribers from one group to another within the same account. Please see the back page for further instructions. Be sure to save a copy of your completed form for your records.

Do not use this form if you or your third-party administrator submits enrollment through electronic enrollment files.

If you have any questions, contact your broker or BCBSRI account representative.

Requestor Information

Client Name

Broker Name

Broker Firm/TPA Name

Prepared by

Email Address

Phone Number

Date Prepared

Member and Request Details

Event Type

Qualifying Event Date

Effective Date of Change

Request Type

Request Action

Change From

Group Number

Sub Group Number

Class

Add or Change to

BCBSRI Member ID Number	Name	Suffix	Date of Birth	Operations
BCBSRI Member ID Number	Name	Suffix	Date of Birth

Proof of prior coverage

Divorce Decree

Common law marriage template is here.
Declaration of domestic partnership template is here.

Declaration and proof of domestic partnership

Declaration and proof of common law

Large group member application template is here.
Small group member application template is here.

Member Application

For dependent /birthday of dependent over age 26, please upload medical certification. Template is here.

Medical Certification

Court Order/Placement Documents

Birth Certificate