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Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company Individual and Senior Dental Enrollment Application for Individuals and Families

If you are an Anthem Blue Cross or Anthem Blue Cross Life and Health Insurance Company member, please enter your current group number and certificate number.

Group no.

Certificate no.

Plan choice — Select one Dental PPO plans provided by Anthem Blue Cross Life and Health Insurance Company

Dental HMO plans provided by Anthem Blue Cross

Dental Blue Basic Dental Blue Enhanced

Other:

_______________________

Dental SelectHMO Other:

If you choose a Dental HMO plan, you must enter the number of the Dental Office you have chosen:

_ _ _ _ _ _ _____________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Application information — Applicant must complete this section Last name

First name

PLEASE PRINT M.I.

Sex

Marital status

Male Female Home address (must be complete; P.O. Box not acceptable)

Single Divorced

Married Domestic Partnership

City

Birth date (Mo/Day/Year)

Social Security no.

State ZIP code

Billing address, if different (or P.O. Box)

City

State ZIP code

Home phone no.

Business phone no.

Spouse/Domestic Partner to be insured Sign below. To be eligible as a Domestic Partner, the Subscriber and Domestic Partner must have properly filed a Declaration of Domestic Partnership with the California Secretary of State pursuant to the California Family Code, or have properly filed an equivalent document

in accordance with the laws of another jurisdiction recognizing the creation of domestic partnerships.

Spouse/Domestic Partner last name

First name

M.I.

Sex

Birth date (Mo/Day/Year)

Social Security no.

Male Female

Sex

Male Female

Sex

Male Female

Sex

Male Female

Sex

Male Female

Children to be insured Last name 1.

First name

M.I.

Birth date (Mo/Day/Year)

Last name 2.

First name

M.I.

Birth date (Mo/Day/Year)

Last name 3.

First name

M.I.

Birth date (Mo/Day/Year)

Last name 4.

First name

M.I.

Birth date (Mo/Day/Year)

Language preference — When

information is sent to you, we may be able to send it in a language other than English. What language would you prefer? (Optional)

Spanish

Chinese

Armenian

Russian

Korean

Other:

Japanese

Tagalog

Vietnamese

Khmer

Hmong

Farsi

Arabic

_______________________

CAINDDENTAPP 6/12

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

MCAFR5301C 6/12 1 of 2

502230 MCAFR5301C IND Dental App File FR 06 12

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