The Indiana health insurance forms and applications listed below are for your convenience. Simply click on the appropriate form and the information can be printed or saved to your computer for future reference. When necessary simply fill out the necessary information, print, and fax to our office at your convenience. You may also e-mail the completed form

Fax: (317) 842-2243
Phone: (317) 842-2210

Forms and Applications

Affordable Care Act Forms:
ACA Enrollment Application

Group Application Forms:
Indiana Group Census Form
Anthem Indiana Employer Application
Anthem Indiana 2-50 Small Group Employee Application

Active Group Forms:
Anthem Indiana New Employee Enrollment Form
Anthem Change of Coverage Form
Anthem Employee Termination Form

Health Applications: 
Anthem All in One Indiana Application
Assurant Health Indiana Individual Application
Celtic Insurance Individual Application
Humana Individual Application
Medical Mutual of Ohio Individual Application
UnitedHealthcare Indiana Individual Application

Dental Applications:
Anthem Dental Application
Brokers National Application