RSDA

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Supply Request

	Fields marked with a red * are required for us to process this form.
	Mailing Labels to R. S. Doughty Associates, Ltd., 3345 106th Circle, Urbandale, IA 50322
	WELLMARK BLUE CROSS BLUE SHIELD PRODUCTS

	**SimplyBlue Under 65 Kits*** (includes all necessary forms listed below)

	M-51950	Health Plans For Individuals and Families Jacket
	M-53818	Health Plans For Individuals and Families QUOTE WORKSHEET
	N-53254	Application for Individual Health, Dental, Life Ins,; (Including BlueTransitions)
	M-50337	SimplyBlue Rate Book
	M-53822	Outline of Coverage AllianceSelect, Comprehensive, Enhanced and Value Plans
	M-53823	Outline of Coverage BluePriority HSA
	M-53815	Outline of Coverage BlueBasics
	M-53866	Understanding the Application Process

	BlueTransitions Kits (Includes App., Rate Book, Outline of Coverage, & Tip Sheet)
	N-5428	Individual Health plan Contract Change Form
	M-5779	Automatic Payment Authorization Form for Wellmark and USAble Life

	MedicareBlue Supplement Enrollemnt Kits - (INCLUDES ALL NECESSARY FORMS LISTED BELOW)

	M-53314	Application for MedicareBlue Supplement
	M-53892	Outline of MedicareBlue Supplement Coverage
	M-53106	Notice to Applicant Regarding Replacement of Medicare Supplement Insurance
	M-53172	SHIIP Insert
	M-6001	Choosing a Medigap Policy: Guide for People with Medicare from CMS/NAIC
	M-51374	MedicareBlue Supplement Enrollment Kit Jacket

	Short Term Major Medical Kits (includes all necessary forms)
	Iowa Uniform Group Health Application – please call RSDA for e-mail download.

	N-5411	Group Application (This application may be used for any size group for additions and changes.)
	S-5003	Alliance Select Provider Directory
	B-0003	Blue Dental Provider Directory
	S-8010	Blue Access/Blue Advantage/Blue Choice Provider Directory

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Supply Request

WELLMARK BLUE CROSS BLUE SHIELD PRODUCTS