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Anthem Life Forms

PW_M010592
Claim Forms 
Accidental Dismemberment or Loss of Sight Claim Form
Beneficiary Designation Form
Life Beneficiary Claim Form - NH
Life Beneficiary Claim Form - CO, CT, IN, KY, ME, MO, NV, OH, VA, WI
Life Waiver of Premium Claim Form
Living Benefit Claim Form
Long-term Disability (LTD) Claim Form
Short-term Disability (STD) Claim Form
 
Electronic Employee Change Forms 
Please contact our customer service department for assistance in making changes. 
Central (IN, KY, MO, OH, WI) - (866) 551-0315 
East (CT, ME, NH, VA) - (866) 551-0326 
West (CO, NV) - (866) 594-0516 
 
Employee Enrollment Forms 
Without Evidence of Insurability 

Colorado and Nevada

Connecticut, Indiana, Missouri, New Hampshire, Ohio and Wisconsin

Kentucky

Maine

New York

Virginia

 
With Evidence of Insurability 

Colorado and Nevada

Connecticut

Indiana

Kentucky

Maine

Missouri, New Hampshire, Ohio and Wisconsin

New York

Virginia

 
Employer Enrollment Forms  
Colorado and Nevada
Connecticut, Indiana, Kentucky, Missouri, Ohio and Wisconsin
Maine
New Hampshire
New York
Virginia
 
Evidence of Insurability Forms 
Colorado Insurability Information Request
Connecticut Insurability Information Request
Indiana Insurability Information Request
Kentucky Insurability Information Request
Maine Insurability Information Request
Missouri Insurability Information Request
Nevada Insurability Information Request
New Hampshire Insurability Information Request
Ohio Insurability Information Request
Virginia Insurability Information Request
Wisconsin Insurability Information Request
New York
 
Portability & Conversion Forms 
Portability Benefit Request Form
Request for Group Life Conversion Information
 
Privacy Notes  
Privacy Note
New York
 
©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