Applications
Enrollment Applications Small Group 2-50
Only use these files for 2-50 plans (new hires, renewals)
- 2018 Small Group 2-50 Member Enrollment Application
- 2017 Small Group 2-50 Member Enrollment Application
- 2016 Small Group 2-50 Combined Member Enrollment Application
Enrollment Applications 2018 Mid Market 51-150 Eligible
Enrollment Applications 2016 Mid Market 51-99
Only use these files for Mid Market 51-99 plans
Enrollment Applications 2016 Mid Market 100-150
Use these files for plans effective dates of 10/1/16 – 12/1/16
Employer Group Enrollment Applications (Small Group and Mid Market)
- 2017 Employer Group Application
- 2016 Employer Group Application
- Virginia Group Health Insurance Medical History Form
- Optima Equity Health Savings Account (HSA) Enrollment Form
- Employer Group Health Questionnaire
- Open Enrollment Spreadsheet
Enrollment Applications (Large Group)
Vantage Member Enrollment Application- Plus Member Enrollment Application
- POS Member Enrollment Application
- Design
Vantage Member Enrollment Application - Design POSA Member Enrollment Application
- Design Plus Member Enrollment Application
- Self Funded Member Enrollment Application
- Equity Plus Member Enrollment Application
- Equity POS Member Enrollment Application
- Equity Vantage Member Enrollment Application
- Open Enrollment Spreadsheet