BluePreferred PPO - Small Group On-SHOP Applications - Virginia

BluePreferred PPO (including HSA/HRA)

Group Size	Group Subscriber Enrollment Form	Group Contract Application
2-50	SUM4736 (for plans effective between 1/1/20 and 12/31/20) SUM5059 (for plans effective 1/1/21 and after)	VA/GRPAPP/HCR (1/20) (HIX) (for plans effective between 1/1/20 and 12/31/20) VA/GRPAPP/HCR (1/21) (HIX) (for plans effective 1/1/21 and after)