Besselman & Little Agency

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Carrier Forms

Assurant Employee Benefits

  • Assurant Application
  • Assurant Beneficiary Designation Form
  • Assurant Change Form

Blue Cross Blue Shield of Louisiana

    BCBS Forms
  • BCBS Enrollment Form
  • BCBS Additional Information
  • BCBS Appeals Form
  • BCBS Dental Claim Form
  • BCBS Dependent Certification
  • BCBS Medical Guide Questionnaire
  • BCBS Other Coverage Questionaire
  • BCBS Prior Carrier Form

  • Express Forms
  • Express Scripts Claim Form
  • Express Scripts Mail Order Form

Coventry

  • Coventry 2 to 19 Enrollment Form
  • Coventry 20 to 35 Enrollment Form
  • Coventry 36+ Enrollment Form

Humana

  • Humana 2-25 Application
  • Humana 26-99 Application
  • Humana Delegation Form
  • Humana Employee Change Form

United Healthcare

  • United 2-99 Application


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Baton Rouge Office

6421 Perkins Road Building A. Suite 2B
Baton Rouge, Louisiana 70808 Phone: (225) 767-0334
Fax: (225) 767-0389 Toll Free: 1-866-862-9255

Click for Directions

New Orleans Office

610 South Peters, Suite 300
New Orleans, LA 70130
Phone: (504) 883-7330
Fax: (504) 883-9123

Click for Directions

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