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)

• 2019 Small Group 1-50 Member Enrollment Application
• 2019 Small Group 1-50 Member Enrollment Application (Spanish)
• 2018 Small Group 1-50 Member Enrollment Application

Enrollment Applications 2019 Mid Market 51-150 Eligible

• 2019 Mid Market 51-150 Member Enrollment Application
• 2019 Mid Market 51-150 Member Enrollment Application (Spanish)
• 2018 Mid Market 51-150 Member Enrollment Application

Employer Group Enrollment Applications (Small Group and Mid Market)

• 2019 Employer Group Application
• 2018 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)

• 2019 Combined Large Group Member Enrollment Application
• 2019 Combined Large Group Member Enrollment Application (Spanish)
• 2018 Combined Large Group Member Enrollment Application
• Self Funded Member Enrollment Application
• Open Enrollment Spreadsheet