An A n t h em ® De Dental ntal Bl ue® Application Please print – complete in blue or black ink only. Important: To be eligibl e to apply for this co verage you must be less than 65 years of age.
Section Section A –App li can t Inf ormat or mat io n
*This information is used for internal purposes only and will not be disclosed.
Home Address (street and P.O. Box if applicable) County
Gender M F
Date of Birth / /
Social Security Number* State
Phone Number ( )
E-mail (not shared with any third party)
If you currently have medical, dental or life l ife coverage through Anthem Blue Cross and Blue Shield: Identification No.
Section Section B –Dental Cov erag e Info rm ation ati on 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 your coverage to s start: tart: _______/_________/________ (MM/DD/YY (MM/DD/YY). ). ® ® ® Dentall Blu e Basic 100 Denta Dental Dental Blue Essential 100 Dental Blue Essential 200
Section C–Spous C–Spous e/D e/Domestic omestic Partner & Chil d 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
Section Section D –Bi –Billll in g In Info form rm ati on Initial Premium
Bank Draft (see below) Credit Card (see below) check payable to Ant hem B lu e Cros s and Bl ue Shi eld )
Frequency (select one) Monthly Quarterly Semi-annually Annually
Premium check enclosed (make
Initial premium amount : $ __________________
Method (select one) HOME – Bills will be t o the address above unless a different address is specified below:
Address (street and PO Box if applicable)
AUTOMATIC BA NK 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) print)
Account holder’s signature
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 Pr emium Payment form to change to automati c 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:
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)
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 aff iliates 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 W isconsin ("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.
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Section Section E –Ag –Agent ent Cert if ic ati on Date
Agent Signature X Agent Name (please print) Agent ID No.
Agent Street Address/Suite No./Personal No./Personal Mail Box (PMB)No. City/State/Zip
Agent Phone No. General Agent (if applicable) (please print)
County Code Agent Fax No.
Agent Email Address General Agent code (if applicable)