For on-exchange policies, please visit your carrier's website:

Anthem BlueCross BlueShield (NH)

For off-exchange policies, please view your carrier's application agreement below:

Anthem BlueCross BlueShield New Hampshire Application Agreement

Important Legal Information

I understand that:

• I must send my first (initial) premium with this application, but it does not mean coverage has been approved. I’m applying for the coverage I chose on this form. To the extent permitted by law, Anthem has the right to accept or decline this application, and that there are no guarantees of any kind just because I filled out this form. If my application is denied, my bank account or credit card will not be charged, and if I paid with a money order, it will be returned to me.

• I’m responsible to let Anthem know, in a timely manner, of any change that would make me or any dependent ineligible for coverage.

• Anthem may change check payments to electronic Automated Clearinghouse (ACH) debit transactions. If this happens, my original check will be destroyed. This charge will appear on my bank statement but my check won’t be given to my financial institution or sent back to me. This charge will not enroll me in any Anthem automatic debit process and will only occur each time I send a check to Anthem. Any resubmissions due to insufficient funds may also occur electronically. All checking transactions will remain secure, and my payment by check means I agree to these terms.

• I agree and consent to the recording and/or monitoring of any telephone conversation between Anthem and myself.

• I’m applying for individual health and/or dental and/or vision coverage which is not part of any employer sponsored plan and I’m responsible for all of the premium payments and making sure that all premiums are paid.

• I certify that each Social Security number listed on this application is correct.

• My domestic partner, if applicable, is only eligible for coverage if: he or she has been my sole domestic partner for 12 months or more; he or she is mentally competent; he or she is not related to me in any way (including by blood or adoption) that would prohibit us from being married under state law; he or she is not married to or separated from anyone else; and he or she is financially interdependent with me.

• I represent that I have read the Important Legal Information section, and I agree to the coverage conditions. I state that the answers given to all questions on this application are true and accurate to the best of my knowledge and belief, and I understand they are being relied on by Anthem in accepting this application. Any act, practice, or omission that constitutes fraud or intentional misrepresentation of material fact found in this application may result in denial of benefits, rescission or cancellation of my coverage(s).

I give this authorization for and on behalf of any eligible dependents and myself if covered by Anthem. I am acting as their agent and representative. This application cannot be altered by the applicant after submission to Anthem absent the acknowledgement and consent of Anthem.

Statement of Premium Payment Acknowledgement

I understand that coverage becomes effective for an eligible member as outlined within this application, provided that the Enrollment Form is completed accurately and in full, and is signed and dated when received by Anthem.

NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND HEALTH INSURANCE

(Only applies if this is replacement policy)

According to the information furnished by you, you intend to lapse or otherwise terminate your present policy and replace it with a policy to be issued by Anthem. For your own information and protection, certain facts should be pointed out to you, which could affect your rights to coverage under the new policy.

a) Health conditions which you may presently have-may not be immediately or fully covered under the new policy. This could result in a claim for benefits being denied or reduced under the new policy, whereas the same claim might have been payable under your present policy. Or, even though some of your present health conditions may be covered under the new policy, these conditions may be subject to certain waiting periods under the new policy before coverage is effective.

b) You may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interest to make sure you understand all the relevant factors involved in replacing your present coverage.

c) If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical/health history. Any act, practice, or omission that constitutes fraud or intentional misrepresentation of material fact found on an application may provide a basis for the company to deny claims that you have incurred and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, re-read it carefully to be certain that all information has been properly recorded.

d) When possible, before you terminate your present policy, be certain that your application for the new policy has been accepted by the replacing company.

By signing this application, I represent that the premium for my coverage will not be paid by a provider of health care services, hospital, non-profit organizations (including religious organizations) that have or whose primary donors have a financial interest in the benefits of the contract/policy, commercial entity with a direct or indirect financial interest in the benefits of the contract/policy or an employer that offers coverage under an employer health plan. I understand that if a third party is paying my premium, Anthem may decline to accept such premium payment if it is made by a person or entity from which it is not required by law to accept.