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PW_M009304
Ready to Apply? Here's how:

 
Choose an Application  

Please choose the appropriate application, print it and then fill it out.

 
Conversion Application
CoreShare Application
Individual Dental Application
Lumenos HSA Plus Application
Short Option Application
Virginia Standard Application
 

 
Medical Condition Questionnaire (if applicable)  
Now that you have filled out the appropriate application, if you answered YES to any of the following medical conditions listed below, click the appropriate questionnaire, print and complete it. Please complete all that apply. If none of the questionnaires apply to you, proceed to step 3. 
 
Asthma
Breast Cancer
Cholesterol
Diabetes
Epilepsy or Seizure
Fracture
High Blood Pressure
Mental Health
Newborn
Other Illness or Injury
 

 
Choose Your Initial Payment Option  

First, select the payment option that best suits your needs:

Bank Draft: It's easy and convenient, saving you time and postage. Just fill out Section 10 on the application and be sure to include your initial payment with your application.

Credit Card: Simply fill out the Credit Card Section on the application and send in your application, following the steps below.

Check: You can fax a copy of your check, along with the application to 1-800-336-2429. Then, just send us the check in the mail with a copy of the first page of your application. Or, you can mail your check and application to the address below.

 

 
Send Your Application 

Now that you've chosen your initial payment method, you're ready to send in your application.

Fax: Faxing your application can save you time and postage--we'll start processing your application right away. Just fax your application and initial payment to 1-800-336-2429.

Mail: You can also mail your initial premium and application to:

 

Anthem Blue Cross and Blue Shield
P. O. Box 14046
Roanoke, VA 24038-4046

 
 
 
©2005-2014 copyright of Anthem Insurance Companies, Inc.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, 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 Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. 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 registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem Web sites constitutes your agreement with our Terms of Use