Anthem Employee Enrollment Application

Employee Enrollment Application For 51+ employee groups
Anthem Employee Enrollment Application
You, the employee, must complete this application. You are solely responsible for its accuracy and completeness. To avoid the possibility of delay, answer all questions and be sure to sign and date your application.
Please complete electronically or in blue or black ink only. Employer name
Group no.
Subsection
Section 1: Employee information
Last name
First name
M.I.
Social Security no.* (required)
Birthdate

MonthDayYear
Date
Home Address
City
County
State
Zip
Sex & Marital Status

MaleFemaleSingleMarriedDomestic Partner
Primary phone no.
Email Address
Employment status

Full timePart timeDisabledRetired
Hire Date

MonthDayYear
Date
Number of hours worked per week
Primary Care Physician (PCP) name
PCP ID no.
Existing patient?

Ye sNo
Reason for Application (Select One)

New enrollmentAnnual open enrollment (not applicable to life and disability)New hireRehire — Rehire date:
Rehire — Rehire date

MonthDayYear
Date
Marriage

Marriage — Date of marriage:
Marriage — Date of marriage

MonthDayYear
Date
Reason for Application (Contd)

Birth of childAdd dependent (Fill in section 4)Loss of eligibility for other coverage — Date previous coverage ended:
Loss of eligibility for other coverage — Date previous coverage ended

MonthDayYear
Date
COBRA — Select qualifying event

Divorce or legal separationLeft employmentReduction in hoursDeathMedicareLoss of dependent child statusCovered employee’s Medicare entitlement
Qualifying Event Date

MonthDayYear
Date
Declining Coverage

Waiver To decline ALL coverage skip to section 8
*Anthem Blue Cross and Blue Shield (Anthem) is required by the Internal Revenue Service to collect this information.

Life and Disability products underwritten by Anthem Life Insurance Company. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, Inc. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. 105109KYMENMUB Rev. 6/19 1 of 8 3414106 105109KYMENMUB LG WGS FI 2020 Member Prt FR 06 19
Social Security no.* (required)
Anthem Essential (PPO) Blue Access (PPO) Blue Preferred (HMO)

Anthem Essential (PPO) Blue Access (PPO)Blue Access PPO HSA Blue Access PPO HSA (with Copay)Blue Access PPO HRA (with Copay)Large Group 51–99 optionsSection 3: Type of coverageBlue Access PPO HRA Blue Access PPO HRA (with Copay)Blue Access PPO HSA Blue Access PPO HSA (with Copay) Blue Access PPO Deductible First HRA
Anthem Essential (PPO) Blue Access (PPO) Blue Preferred (HMO)

Anthem Essential (PPO) Blue Access (PPO) Blue Preferred (HMO)Large Group 100+ optionsMedical coverageSocial Security no.* (required)Anthem Essential (PPO) Blue Access (PPO) Blue Preferred (HMO)Blue Access PPO HSA Blue Access PPO HSA (with Copay) Blue Access PPO Deductible First HRA
Member medical coverage — select one:
Member Medical Coverage

Employee onlyEmployee + Spouse/Domestic PartnerEmployee + child(ren)FamilyNo coverage
Flexible Spending Account (FSA) Coverage

Healthcare FSA (excluded if you have an HSA plan) Limited-Purpose FSA (for dental and vision services) Dependent Care FSACommuter Parking Commuter Transit No FSA coverage at this timeLimited Purpose FSA (for dental and vision services)Commuter TransitDependent Care FSANo FSA Coverage at this time
Dental Coverage

Employee OnlyEmployee + Spouse/Domestic PartnerEmployee + child(ren)FamilyNo coveragePrime Essential ChoiceComplete Essential ChoiceOther
Vision Coverage

Accept Vision CoverageEmployee OnlyEmployee + Spouse/Domestic PartnerEmployee + child(ren)FamilyNo coverage
Life and Disability Coverage. If you select life and/or disability coverage over the guaranteed issue amount or are a late entrant an Evidence of Insurability form may be sent to you to complete.

Basic LifeBasic Life and Accidental Death and DismembermentBasic Dependent LifeOptional Supplemental/Voluntary Life and Accidental Death and DismembermentOptional Supplemental/Voluntary Dependent Life SpouseOptional Supplemental/Voluntary Dependent LifeVoluntary Accidental Death and DismembermentVoluntary Accidental Death and Dismemberment Family Plan (Spouse and Child coverageVoluntary Accidental Death and Dismemberment Spouse Only (no Child coverage)Voluntary Accidental Death and Dismemberment Child Only (no Spouse coverage)Short Term DisabilityLong Term DisabilityVoluntary Short Term DisabilityVoluntary Long Term Disability
Current annual income — For employer/Anthem use
Occupation
Life and disability class no.— For employer/Anthem use
*Anthem is required by the Internal Revenue Service to collect this information.
Social Security no.* (required)
Primary Beneficiary Name

First nameLast name
M.I.
Birthdate (MM/DD/YYYY)

MonthDayYear
Date
Social Security no.* (required)
Relationship to applicant
Address
Percentage to be paid to beneficiary
Name

First nameLast name
M.I.
Birthdate (MM/DD/YYYY)

MonthDayYear
Date
Social Security no.* (required)
Relationship to applicant
Address
Percentage to be paid to beneficiary
Contingent beneficiary — If no primary beneficiary survives, the proceeds will be paid to the contingent beneficiary(ies) listed.
Name

First nameLast name
M.I.
Birthdate (MM/DD/YYYY)

MonthDayYear
Date
Social Security no.* (required)
Relationship to applicant
Address
Percentage to be paid to beneficiary
Name

First nameLast name
M.I.
Birthdate (MM/DD/YYYY)

MonthDayYear
Date
Social Security no.* (required)
Relationship to applicant
Address
Percentage to be paid to beneficiary
Total percentages should add up to 100%. If no percentages are indicated, the proceeds will be divided equally.
Spousal consent for community property states only Note: The insurance company is not responsible for the validity of a spouse’s consent for designation If you live in a community property state AZ, CA, ID, LA, NM, NV, TX, WA and WI, your state may require you to obtain the signature of your spouse if your spouse will not be named as a primary beneficiary for 50% or more of your benefit amount. Please have your spouse read and sign the following. I am aware that my spouse, the Employee/Retiree named above, has designated someone other than me to be the beneficiary of group life insurance under the above policy. I hereby consent to such designation and waive any rights I may have to the proceeds of such insurance under applicable community property laws. I understand that this consent and waiver supersedes any prior spousal consent or waiver under this plan. Spouse signatureSpouse nameDate MM/DD/YYYY
Spousal consent for community property states only Note: The insurance company is not responsible for the validity of a spouse’s consent for designation If you live in a community property state AZ, CA, ID, LA, NM, NV, TX, WA and WI, your state may require you to obtain the signature of your spouse if your spouse will not be named as a primary beneficiary for 50% or more of your benefit amount. Please have your spouse read and sign the following. I am aware that my spouse, the Employee/Retiree named above, has designated someone other than me to be the beneficiary of group life insurance under the above policy. I hereby consent to such designation and waive any rights I may have to the proceeds of such insurance under applicable community property laws. I understand that this consent and waiver supersedes any prior spousal consent or waiver under this plan. Spouse signatureSpouse nameDate MM/DD/YYYY

MonthDayYear
Date
*Anthem is required by the Internal Revenue Service to collect this information.
Social Security no.* (required)
Voluntary Accident Insurance — Coverage option: If more than one Accident plan offered please select:
Employee + Spouse High Plan Yes, explain product used
Voluntary Accident, Critical Illness, and Hospital Indemnity Insurance

In each section, if more than one Accident plan is offered, please select High or Low Plan
Voluntary Accident insurance

Voluntary Accident Insurance (check if receiving) — Coverage option:Employee onlyEmployee + SpouseEmployee + ChildrenFamilyLow PlanHigh Plan
Voluntary Critical Illness Insurance

Voluntary Critical Illness Insurance (check if receiving) — Coverage option:Employee onlyEmployee + SpouseEmployee + ChildrenFamilyLow PlanHigh PlanNo I have not smoked or used tobacco products in the last 12 monthsYes I have smoked or used tobacco products in the last 12 months
If answering Yes above, explain product used:
Voluntary Hospital Indemnity Insurance

Voluntary Hospital Indemnity Insurance (check if receiving) — Coverage option:Employee onlyEmployee + SpouseEmployee + ChildrenFamilyLow PlanHigh Plan
If any person to be covered by a Critical Illness or Hospital Indemnity plan is a resident of CA, GA, NY or CO, please answer the following question: Will all applicants who reside in CA, GA, NY, or CO , when such coverage is to become effective, be enrolled in comprehensive health benefits from an individual or group health insurance policy, an employer sponsored health plan, or an HMO that provides essential health benefits? Ye sNo (Please note that if the response is No, such applicants are not eligible for coverage)

YesNo
Voluntary Accident, Critical Illness, and Hospital Indemnity Insurance primary beneficiary designation
Name

First nameLast name
M.I.
Birthdate (MM/DD/YYYY)

MonthDayYear
Date
Social Security no.* (required)
Relationship to applicant
Address
Percentage to be paid to beneficiary
Name

First nameLast name
M.I.
Birthdate (MM/DD/YYYY)

MonthDayYear
Date
Social Security no.* (required)
Relationship to applicant
Address
Percentage to be paid to beneficiary
Contingent beneficiary — If no primary beneficiary survives, the proceeds will be paid to the contingent beneficiary(ies) listed.
Name

First nameLast name
M.I.
Birthdate (MM/DD/YYYY)

MonthDayYear
Date
Social Security no.* (required)
Relationship to applicant
Address
Percentage to be paid to beneficiary
Name

First nameLast name
M.I.
Birthdate (MM/DD/YYYY)

MonthDayYear
Date
Social Security no.* (required)
Relationship to applicant
Address
Percentage to be paid to beneficiary
Total percentages should add up to 100%. If no percentages are indicated, the proceeds will be divided equally.

*Anthem is required by the Internal Revenue Service to collect this information.
Social Security no.* (required)
Section 4: Coverage information — All fields required. Attach a separate sheet if necessary.

Dependent information must be completed for all additional dependents (if any) to be covered under this coverage. An eligible dependent may be your spouse or domestic partner, your children, or your spouse or domestic partner’s children (to the end of the calendar month in which they turn age 26 unless they qualify as a disabled person List all dependents beginning with the eldest. Note: Domestic partner coverage is not available for life and disability plans.
Spouse/Domestic Partner Name

First nameSpouse/Domestic Partner last name
M.I.
Social Security no.* (required)
Sex

MaleFemale
Sex

YesNo
Birthdate

MonthDayYear
Date
Relationship to applicant

SpouseDomestic Partner
PCP name
PCP ID no.
Existing patient?

YesNo
Dependent Name

First nameDependent last name
M.I.
Social Security no.* (required)
Sex

MaleFemaleBiological child of applicant/spouse/domestic partner.If not the biological child of applicant/spouse/domestic partner, please define relationship
Disabled

YesNo
Birthdate (MM/DD/YYYY)

MonthDayYear
Date
PCP name
PCP ID no.
Existing patient?

YesNo
Does this dependent have a different address?

YesNo
If yes, please enter
Additional Dependent Name

First nameDependent last name
M.I.
Social Security no.* (required)
Sex

MaleFemaleBiological chid of applicant/spouse/domestic partner.If not the biological child of applicant/spouse/domestic partner, please define relationship
Disabled

YesNo
Birthdate (MM/DD/YYYY)

MonthDayYear
Date
PCP name
PCP ID no.
Existing patient?

YesNo
Does this dependent have a different address?

YesNo
If yes, please enter
Additional Dependent Name

First nameDependent last name
M.I.
Social Security no.* (required)
Sex

MaleFemaleBiological chid of applicant/spouse/domestic partner.If not the biological child of applicant/spouse/domestic partner, please define relationship
Birthdate (MM/DD/YYYY)

MonthDayYear
Date
Disabled

YesNo
PCP name
PCP ID no.
Existing patient?

YesNo
Does this dependent have a different address?

YesNo
If yes, please enter
*Anthem is required by the Internal Revenue Service to collect this information.
Social Security no.* (required)
Section 5: Prior and other group coverage
Are you or anyone applying for coverage currently eligible for Medicare?

YesNo
If yes, give name
Medicare ID no.
Part A effective date

MonthDayYear
Date
Part B effective date

MonthDayYear
Date
Medicare Eligibility Reason

AgeDisabilityESRD onset date
Medicare Part D ID no.
Medicare Part D carrier
Medicare Part D effective date

MonthDayYear
Date
Are you or a family member previously or currently covered by a Medicare, medical and/or dental plan?

YesNo
If yes, please provide the following:
Name of person A covered Last name, first, M.I
Type

IndividualGroupMedicareMedicalDentalOrthodontia

Additional Information

	Carrier name	Carrier phone no.	Policy ID no.	Policyholder name
Covered

Start

MonthDayYear
Date
End

MonthDayYear
Date
Name of person B covered Last name, first, M.I
Type

IndividualGroupMedicareMedicalDentalOrthodontia

Additional Information

	Carrier name	Carrier phone no.	Policy ID no.	Policyholder name
Covered

Start

MonthDayYear
Date
End

MonthDayYear
Date
Name of person C covered Last name, first, M.I
Type

IndividualGroupMedicareMedicalDentalOrthodontia

Additional Information

	Carrier name	Carrier phone no.	Policy ID no.	Policyholder name
Covered

Start

MonthDayYear
Date
End

MonthDayYear
Date
Name of person D covered Last name, first, M.I
Type

IndividualGroupMedicareMedicalDentalOrthodontia

Additional Information

	Carrier name	Carrier phone no.	Policy ID no.	Policyholder name
Covered

Start

MonthDayYear
Date
End

MonthDayYear
Date
Name of person E covered Last name, first, M.I
Type

IndividualGroupMedicareMedicalDentalOrthodontia

Additional Information

	Carrier name	Carrier phone no.	Policy ID no.	Policyholder name
Covered

Start

MonthDayYear
Date
End

MonthDayYear
Date
Anthem is required by the Internal Revenue Service to collect this information.
Social Security no.* (required)
Section 6: Terms, Conditions and Authorizations (TERMS)
Please read this section carefully before signing the application.

Genetic Information Non-discrimination Act (GINA): When answering questions about a person on this form, only give answers about that person, and do not include any genetic information. Genetic information includes family health history, genetic testing, genetic services, genetic counseling, or genetic diseases for which the person may be at risk. All responses about a person will only be considered and used for that person. Health Savings Account Notice: I authorize the financial custodian of my Health Savings Account (HSA) to give Anthem Blue Cross and Blue Shield (Anthem) facts about my HSA, including account number, account balance and account activity. I understand that I may take back my authorization by written request to Anthem at any time. 1. I understand that I may not assign any payment under my Anthem 4. I agree that I will let my employer know right away of any changes that program unless allowable by law.would make me or any dependent(s) ineligible for this coverage. 2. I agree to have money taken from my wages/pension, if necessary, 5. By signing this application, I agree to the taping or monitoring of any to cover the premium cost for the coverage applied for.phone calls between Anthem and myself. 3. I am asking for the coverage I chose on this form. If I made choices that are not available to me, I agree that my choices may be changed to those on the employer’s application. Any person who knowingly and with intent to defraud any insurance company, health maintenance organization, self-insured plan, or other person, files an application for insurance or other form of health care coverage containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. I have read and accept the Terms, Conditions and Authorizations as a condition of coverage. I represent that my answers to all questions are true to the best of my knowledge, and I understand that Anthem relies on these answers in accepting this application. I understand that any untrue answers or failure to report new medical information before my approval date may cause a material change in coverage or premium rates. Any materially false statement or misrepresentation found in this application may result in denial of benefits, rescission or cancellation of coverage. I agree to these terms for myself and on behalf of any dependents covered by the Plan. I am acting as their agent and representative. I certify each Social Security number listed on this application is correct. By signing this application, I understand that I will get information about my benefits by email or electronically. This may include my certificate or evidence of coverage, explanation of benefits statements, required notices and helpful or personalized information to get the most out of my plan, so I will make sure Anthem has my most up to date email. These electronic communications may include specific details about me and my plan. After I enroll, I can change my communication preferences by calling Member Services or going to anthem.com. I can also call Member Services to request a free copy of specific materials by mail. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, Inc.

Thank you for choosing Anthem Blue Cross and Blue Shield.

Section 7: Signature — Required if you are applying for coverage. Please review your application for errors or omissions.

Read section 6 carefully before signing.

I have read and understand the language in the TERMS section of this application and agree to all of its terms. Employee signature
Signature

Clear
Date (MM/DD/YYYY)

MonthDayYear
Date
Important Accident Insurance eligibility information:

The following notice applies to all Accident and Voluntary Accident coverage presented on this form:

ACCIDENT INSURANCE IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. THIS IS NOT A QUALIFYING HEALTH COVERAGE (“MINIMUM ESSENTIAL COVERAGE”) THAT SATISFIES THE HEALTH COVERAGE REQUIREMENT OF THE AFFORDABLE CARE ACT. IF YOU DON’T HAVE MINIMUM ESSENTIAL COVERAGE, YOU MAY OWE AN ADDITIONAL PAYMENT WITH YOUR TAXES.

Important Critical Illness Insurance eligibility information:

The following notice(s) apply to all Critical Illness and Voluntary Critical Illness coverage presented on this form:

CRITICAL ILLNESS INSURANCE IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. THIS IS NOT QUALIFYING HEALTH COVERAGE (“MINIMUM ESSENTIAL COVERAGE”) THAT SATISFIES THE HEALTH COVERAGE REQUIREMENT OF THE AFFORDABLE CARE ACT. IF YOU DON’T HAVE MINIMUM ESSENTIAL COVERAGE, YOU MAY OWE AN ADDITIONAL PAYMENT WITH YOUR TAXES.

Important Hospital Indemnity Insurance eligibility information:

The following notice applies to all Hospital Indemnity and Voluntary Hospital Indemnity coverage presented on this form:

HOSPITAL INDEMNITY INSURANCE IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. THIS IS NOT A QUALIFYING HEALTH COVERAGE (“MINIMUM ESSENTIAL COVERAGE”) THAT SATISFIES THE HEALTH COVERAGE REQUIREMENT OF THE AFFORDABLE CARE ACT. IF YOU DON’T HAVE MINIMUM ESSENTIAL COVERAGE, YOU MAY OWE AN ADDITIONAL PAYMENT WITH YOUR TAXES.

*Anthem is required by the Internal Revenue Service to collect this information.
Social Security no.* (required)
Medical coverage declined for — check all that apply

MyselfSpouse/domestic partnerDependent(s)
Reason for declining coverage — check all that apply

Covered by spouse/domestic partner's group coverageEnrolled in individual coverageSpouse covered by employer's group medical coverageMedicare/Medicaid/VANo CoverageEnrolled in other insurance — Please provide company name and plan
If you are declining coverage for another reason or healthcare plan, please explain:
Dental coverage declined for — check all that apply

MyselfSpouse/domestic partnerDependent(s)
Reason for declining coverage — check all that apply

Covered by spouse/domestic partner's group coverageEnrolled in individual coverageSpouse covered by employer's group medical coverageMedicare/Medicaid/VANo CoverageEnrolled in other insurance — Please provide company name and plan
If you are declining coverage for another reason or healthcare plan, please explain:
Vision coverage declined for — check all that apply

MyselfSpouse/domestic partnerDependent(s)
Reason for declining coverage — check all that apply

Covered by spouse/domestic partner's group coverageEnrolled in individual coverageSpouse covered by employer's group medical coverageMedicare/Medicaid/VANo CoverageEnrolled in other insurance — Please provide company name and plan
If you are declining coverage for another reason or healthcare plan, please explain:
Life and disability coverage

* Life/AD&D coverage declined for myself: Spouse and dependent coverage not available if life coverage is waived/declined.Dependent Life coverage declined for: Spouse and dependentsOptional Supplemental/Voluntary coverage declined for: MyselfOptional Supplemental/Voluntary Dependent Life coverage declined for: Spouse and DependentsVoluntary Short Term Disability coverage declined for: MyselfVoluntary Long Term Disability coverage declined for: Myself
Reason for declining coverage (check all that apply)

Life/AD&D declined for religious reasonsDo not elect to enroll in Dependent LifeDo not elect to enroll in Optional Supplemental/Voluntary coverageDo not elect to enroll in Optional Supplemental/Voluntary Dependent Life coverageDo not elect to enroll in Voluntary Short Term DisabilityDo not elect to enroll in Voluntary Long Term Disability
I hereby certify that I have been given the opportunity to apply for the available group life benefits offered by my employer, the benefits have been explained to me, and I and/or my dependent(s) decline to participate. Neither I nor my dependent(s) were induced or pressured by my employer, agent, or life carrier, into declining this coverage, but elected of my (our) own accord to decline coverage. I understand that if I wish to apply for such coverage in the future, I may be required to provide evidence of insurability at my expense.*
Sign here only if you are declining coverage.
Signature

Clear
Printed name
Social Security no.
Date (MM/DD/YYYY)

MonthDayYear
Date
Anthem Health Plans of Kentucky, Inc: 13550 Triton Park Blvd. Louisville, KY 40223 Anthem Life Insurance Company: P.O. Box 105448, Atlanta, GA 30348-5448

*Anthem is required by the Internal Revenue Service to collect this information.
Get help in your language
Language Assistance Services
Curious to know what all this says? We would be too. Here’s the English version: If you need assistance to understand this document in an alternate language, you may request it at no additional cost by calling the Member Services number (855-738-6671 (TTY/TDD: 711)

Separate from our language assistance program, we make documents available in alternate formats for members with visual impairments. If you need a copy of this document in an alternate format, please call the Member Services telephone number on the back of your ID card.

Spanish Si necesita ayuda para entender este documento en otro idioma, puede solicitarla sin costo adicional llamando al número de Servicios para Miembros (855-738-6671 (TTY/TDD: 711)

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855-738-6671 TTY/TDD: 711
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855-738-6671 TTY/TDD: 711
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It’s important we treat you fairly

That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711 If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368-1019 (TDD: 1- 800 537-7697) or online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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.
Should be Empty:

Anthem Employee Enrollment Application

Voluntary Accident, Critical Illness, and Hospital Indemnity Insurance

Section 6: Terms, Conditions and Authorizations (TERMS)

Get help in your language

Language Assistance Services

855-738-6671 TTY/TDD: 711

855-738-6671 TTY/TDD: 711