Anthem Dental App 2013

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Anthem® Dental Blue® Application
Please print – complete in blue or black ink only. Important: To be eligible to apply for this coverage you must be less than 65 years of age.

Section A–Applicant Information
Last Name Home Address (street and P.O. Box if applicable) County Gender M F Date of Birth / / First Name

*This information is used for internal purposes only and will not be disclosed.
MI City Age Phone Number ( ) Social Security Number* State ZIP

E-mail (not shared with any third party)

If you currently have medical, dental or life coverage through Anthem Blue Cross and Blue Shield: Identification No.

Section B–Dental Coverage Information
Effective date requested: If your application is approved, your coverage can start on any day of the month after the date we receive your application. Please choose the date you would like your coverage to start: _______/_________/________ (MM/DD/YY). ® ® ® Dental Blue Basic 100 Dental Blue Essential 100 Dental Blue Essential 200

Section C–Spouse/Domestic Partner & Child Dependents to be Covered Information
] )

(All fields required, attach separate sheet if needed)

Dependent information must be completed for all additional dependents (if any) to be covered. List all dependents beginning with the eldest. First, MI (last name, if different) Relationship to Applicant Social Security Number* Gender Age Date of Birth
Spouse/ Domestic Partner [Child] [Child] [Child]

M M M M

F F F F

/ / / /

/ / / /

Section D–Billing Information
Frequency (select one) Monthly Quarterly Semi-annually Annually Initial Premium Bank Draft (see below) Credit Card (see below) check payable to Anthem Blue Cross and Blue Shield) Premium check enclosed (make

Initial premium amount: $ __________________ Method (select one) HOME – Bills will be to the address above unless a different address is specified below:

Name

Address (street and PO Box if applicable)

City

State

ZIP

AUTOMATIC BANK DRAFT – Premium is deducted on the same day of the month as your effective date; you must attach a blank, voided check.
If selecting Automatic Bank Draft: I authorize Anthem Blue Cross and Blue Shield to initiate premium deductions from the checking account indicated and the designated financial institution to debit the same account. This authorization is in effect until I notify Anthem in writing that I no longer desire this service, allowing Anthem reasonable time to act upon my notification. I understand Anthem and my financial institution have the right to discontinue the withdrawals at their discretion.

Account holder’s name (please print) X

Account holder’s signature X

CREDIT CARD – A credit card can be used only for this initial premium payment. If your application is accepted, you will be billed directly for future payments or you may request a Premium Payment form to change to automatic bank withdrawal. Your credit card will not be charged unless you are approved for coverage. Cardholder’s Name (as shown on the credit card) and Address: X
I authorize Anthem Blue Cross and Blue Shield to charge the credit card indicated for the amount specified in Initial Premium (above). If applicant is using the credit card of another cardholder: By signing this form, applicant represents and warrants that he/she has the cardholder’s authorization to use this card and, if not, that he/she will take full responsibility for this payment and any charges accruing to it.

Type of Credit Card:

VISA

MasterCard

Discover

Amex

Applicant’s Signature Date Date

Credit Card Number _______________________________________ Expiration Date (month/year): _________ / _________ Signature of Applicant (if age 18 or older, or Custodial Parent’s or Guardian’s signature if applicant is under age 18) Signature of Spouse or Domestic Partner (if enrolling) Date Signature of Dependent/Child (18 or over, if enrolling)

Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. Anthem Blue Cross and Blue Shield is the trade name of: In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Ohio: Community Insurance Company. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are the registered marks of the Blue Cross and Blue Shield Association.

ADB Rev 0210 Page 1 of 2

Section E–Agent Certification
Agent Signature X Agent Name (please print) Agent ID No. Agent Phone No. General Agent (if applicable) (please print) City/State/Zip Agent Fax No. Agent Street Address/Suite No./Personal Mail Box (PMB)No. County Code Agent Email Address General Agent code (if applicable) Area Date

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