Small Group Member Application Form

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Small Group Member Application
for VantageBlue Select, Dental and Vision Insurance
Please be sure ALL information below is complete to avoid delays in processing.
Please print clearly using blue or black ink or type in information.
Employer Information (To be completed by plan administrator.)
Section 1
Group name
_________Effective date___ / ___ / ______
Date of hire ___ / ___ / ______
Group number
Department number __________________________________________
Choose one:
Add dependent(s)
c Open enrollment
c Spouse
c New hire
c Dependent
( Must apply within 30 days of marriage, birth,
c Loss of coverage (Evidence of prior coverage)
or adoption of dependent.)
c Other___________________________________
Section 2
Employee Information
Last name
First name
_____________ M.I.
Home address
_________ State
ZIP code
Mailing address
Date of birth (mm/dd/yyyy) ___ / ___ / ______
Gender c M c F
Social security number
Home phone number
Cell phone number
Marital status (please check one) c Single c Married c Divorced c Common Law c Civil Union c Domestic Partner
What is your primary language spoken?
E-mail address
Race (please check one)
c Prefer not to answer
c American Indian or Alaska Native c Asian c Black or African American c Hispanic or Latino
c Multiracial c Native Hawaiian or other Pacific Islander c White
Primary care physician (PCP) name, address
Are you a current patient? c Yes
c No
Social Security number is required in order to comply with the reporting requirements of the Mandatory Insurance Reporting Law.
By choosing the VantageBlue Select plan, you must select a Primary Care Physician (PCP) and other healthcare providers (including hospitals, specialists, labs, and durable
medical equipment suppliers) from the VantageBlue Select network in order to get the lowest out-of-pocket healthcare costs (e.g., copayments and coinsurance).
Providers in the VantageBlue Select network can be found at or in the Find A Doctor tool on . If you do not seek services
from a VantageBlue Select network provider or receive a network referral you will be responsible for the applicable higher out-of-network cost sharing.
continued ➤
VBSAPP (10/15)


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