Applications
BusinessEDGE®
- BusinessEDGE® Employee Enrollment Application (Height and Weight must be included for both underwriting and applying for coverage)
- BusinessEDGE® Employee Enrollment Application (Spanish)
Enrollment Applications Small Group 1-50
Only use these files for 1-50 plans (new hires, renewals)
- 2020 Small Group 1-50 Member Enrollment Application
- 2020 Small Group 1-50 Member Enrollment Application (Spanish)
- 2019 Small Group 1-50 Member Enrollment Application
- 2019 Small Group 1-50 Member Enrollment Application (Spanish)
Enrollment Applications 2019 Mid Market 51-150 Eligible
- 2020 Mid Market 51-150 Member Enrollment Application
- 2020 Mid Market 51-150 Member Enrollment Application (Spanish)
- 2019 Mid Market 51-150 Member Enrollment Application
- 2019 Mid Market 51-150 Member Enrollment Application (Spanish)
Employer Group Enrollment Applications (Small Group and Mid Market)
- 2020 Employer Group Application
- 2019 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
- 1099 Eligibility and Attestation Form
Enrollment Applications (Large Group)
- 2020 Combined Large Group Member Enrollment Application
- 2020 Combined Large Group Member Enrollment Application (Spanish)
- 2019 Combined Large Group Member Enrollment Application
- 2019 Combined Large Group Member Enrollment Application (Spanish)
- Self Funded Member Enrollment Application
- Open Enrollment Spreadsheet