Get Anthem Extras Packages Senior Enrollment Application Form

Filling out the Anthem Extras Packages Senior Enrollment Application Form online is a straightforward process designed to gather essential information for eligibility and coverage. This guide will walk you through each section of the form, ensuring you complete it accurately and efficiently.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with Section A – Applicant Information. Fill in your last name, first name, and middle initial. Provide your social security number, home address, city, state, ZIP code, and county. If your mailing address is different, include that information as well. Ensure all information is complete; P.O. Box addresses are not acceptable.
3. Continue filling in your age, gender, date of birth, daytime and evening phone numbers, and email address. If you have existing medical or dental coverage with Anthem, include your member identification number, effective date, and termination date.
4. Move to Section B – Coverage Information. Indicate the requested effective date for your coverage, which can start any day of the month after your application is received. Choose from the coverage packages available.
5. Proceed to Section C – Billing Information. Select your preferred billing frequency (monthly, quarterly, semi-annually, or annually). Indicate your initial premium method by selecting either automatic bank draft or premium check enclosed, and write the total amount enclosed.
6. If selecting automatic bank draft, be sure to attach a voided check and complete the authorization statement for premium deductions. Provide the account holder's name and signature as necessary.
7. Review Section D – Agreement Signature Required. Read the fraud disclaimer carefully, and sign by the applicant, legal guardian, or power of attorney. Include the date of your signature.
8. Complete Section E – Agent Certification if applicable. The agent will fill in their information, sign, and provide any required details if they assisted you with the application.
9. After completing all sections of the form, review the information for accuracy. Once verified, save your changes. You can download a copy, print it, or share it as needed before submission.

Complete your application online today to ensure your coverage is processed promptly.