Kentucky
Dental Broker Rate Calculator – Password Request Form
Small Group Quoting Tool for 2-50 Eligible Employees
For assistance with this form, call toll free: 1-866-956-8602
To receive an ID and Password to use Anthem’s secure dental Broker Rate Calculator, please complete the first two sections of this form (one form per user). When completed, fax to Anthem Connect at 1-877-604-2124 or e-mail it to .
Section 1: BROKERAGE COMPANY INFORMATIONToday’s Date: / Main Broker Agency Contact:
Broker Agency Name & Address: / Main Contact E-Mail:
Main Contact Phone:
Section 2: SPECIFIC USER INFORMATION (all fields are required)
Username: / User Phone:
User Job Title: / User Signature:
Business E-Mail:
USER PASSWORD INFORMATION
(to be completed by Anthem Security)
Assigned Username: / Application: Rate Calculator
SECURITY INFORMATION
(to be completed by Anthem Connect Representative)
Completed Form: Yes No
Anthem Connect Initial: / Date Submitted:
Date Assigned:
www.anthem.com
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
2/2014