Health Insurance from Blue Cross and Blue Shield of North Carolina

Lorrie Maxwell · Mike Bender · Mark Thacker

An Authorized Agency of
Blue Cross and Blue Shield of North Carolina® since 1992




Applicant's Information

	First Name: Last Name:
	Date of Birth:
	Gender: Male Female Maternity: Yes No

Spouse's Information (If applying)

	First Name: Last Name:
	Date of Birth:

Child Information (If applying)

	Child #1: Date of Birth:
	Gender: Male Female

	Child #2: Date of Birth:
	Gender: Male Female

	Child #3: Date of Birth:
	Gender: Male Female

	Child #4: Date of Birth:
	Gender: Male Female

	* Email Address:
	* County of Residence: *Zip:
	* Indicates a required field

If you have any questions, please give us a call at
1-800-588-9025

Apply Today for North Carolina's
Number One Health Coverage⁺

Insurance Answers Inc. is an independent authorized agency licensed to sell and promote products from
Blue Cross and Blue Shield of North Carolina® (BCBSNC).