This insurance company is licensed to issue insurance policies in Florida. The department sends a letter notifying you to provide the required insurance coverage information.Please use this template to assist in the process of providing verification of coverage. This letter must be printed on your company letterhead. How do I fill this out? Forms for members enrolled in individual, family and employer plans with Florida Blue. This page is designed to provide you with the forms necessary to obtain or maintain your license. (HOI) contract contains a coordination of benefits. All sections of the form must be filled out completely or your claim may be returned to you. However, using the information on your Form 1095-A you must complete and file Form 8962, Premium Tax Credit.