Anthem Off-­Exchange Application

The Off­-Exchange Application can be utilized for initial enrollment into a private off­-exchange health insurance policy under Anthem Blue Cross and Blue Shield. The application is often used as a change form for adding or removing dependents throughout the policy year when a special election period is applicable like a marriage, birth, divorce, or death. Once the form is completed for change or enrollment, all submissions must be handled through our staff before submitting to the insurance carrier.

FORM  – Anthem Off-Exchange Application

Exchange Questionnaire

In order to prepare the most accurate premium estimates, subsidy assumptions, and plan option comparison our firm requires a fully completed Exchange Questionnaire which includes a description of your household location, dependents, and income estimates from all sources for the upcoming plan year. The Exchange Questionnaire is to include a listing of all family members living in your home whether or not they will be electing insurance. All income including that of a child is to be included as well.

FORM – Exchange Questionnaire 2016

Medical Mutual Off­-Exchange Application

The Off­-Exchange Application can be utilized for initial enrollment into a private off­-exchange health insurance policy under Medical Mutual. The application is often used as a change form for adding or removing dependents throughout the policy year when a special election period is applicable like a marriage, birth, divorce, or death. Once the form is completed for change or enrollment, all submissions must be handled through our staff before submitting to the insurance carrier.

FORM – Medical Mutual Off-Exchange Application

Medicare Scope of Appointment

The understanding and completion of the Medicare Scope of Appointment document is mandatory prior to all Medicare Sales Presentations where a face to face meeting will occur with any of our agents or brokers. Initialing of the front page where applicable and signing the signature line along with date on the second page are the only requirements of the form. The agent or broker will complete the remaining.

FORM – Medicare Scope of Appointment

Notice of Privacy Practices

The Notice of Privacy Practices explains how our agency treats private health information or PHI. Our duty to keep your information safe and secure is our utmost priority. This notice is for informational purposes only and is not required for obtaining a quote or proposal.

FORM – Notice of Privacy Practices -IEN

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