Forms

Change of Address Form

• Change of Address Form – use this form to notify us if you have moved.
• Text Message Communications – use this form to communicate with us via text message.

Travel Insurance

• IMG – Get Quote, Plan Details or Apply Online

Individual & Families Insurance Forms

Independence Blue Cross – Personal Choice PPO and Keystone HMO Health Plans

• Plan Rates 2024
• Plan Summaries 2024
• Enrollment Form 2023
• Plan Rates 2023
• Plan Summaries 2023
• Enrollment Form 2023

Aetna Advantage Health Plans

• Contact Brad or Randy for more info

Short Term Medical Plans

• Contact Randy or Brad for a short term medical quote

Dental & Vision Plans

• Delta for Everyone (apply online or get a quote)
• Independence Adult Dental Plan 2023 (pdf)
• Independence Adult Dental Application 2023 (pdf)
• Independence Adult Vision Plan 2023 (pdf)
• Independence Adult Vision Application 2023 (pdf)

Business & Group Insurance Forms

Independence Blue Cross – Keystone and Personal Choice

• Small Group Plan Guide 2023 (pdf)
• Employer application (pdf)
• Employee enrollment form (pdf)

Insurance Request Forms

• Certificate of Insurance Request form – use this form to notify us if you need a certificate of insurance coverage