HealthInsuranceEnrollmentForm

Member Enrollment/Member Change Form

To he completed by employer
Firm division no.

Heaith benefit plan

Anthem. faa
BlueCross BlueShield iO,

Requested effective date (MM/DD/YYYY)

 

Current Anthem contract no., if any |Last name

Home street address or P.0. box
Home phone ne. -.
Email address

8! a

CINew group (initial enrollment)
CICOBRA/CGS 38A-538: Reason:

Work phone no,

DAnnual enrollment.

First name
City

Marital status: [J Single
CiMarried

CNew hire

 

Type of change
Cl Name (indicate farmer name):

ClAccess Blue New En
CoBiue Care
C1 Blue Choice New England
oO Preferred/PPO
O Preferred/EPO
(CIHMO Blue New

- {COHSA? Plan
CUHRA Plan
COHIA Plan
CDental
C1 Blue View Vision
C0ther

Plan name:

Plan name:
Plan name:

Plan name,
Plan name:

Plan name:
Plan name:
Plan name:

~(CAddress (1 Other reason:

= Andividual’)". Two person

Lumenos HDHP with HSA

Oooo Oo Oo

State ZIP code

OWidowed
ODivorced

(CJ Legally separated

CiSeparated

Qualifying event date:

Bate:

Family)

Oooo Oooo
Oooo OO ooo

Are you or any other eligible dependent fisted on this form currently confined to a hospital or other health care facility, totally disabled or physically impaired?

Clyes CINo

Company name

Are you actively at work? L1Yes CINo
Ifno, reason; C1 Sick Cinjured

Date of full-time hire? of part-time hire?

1 Confirm with your

r which HSA custodian was selected.

Are you currently cl
Dyes ON

Date of rehire? (if applicable
Clyes CINo

Workers’ Compensation medical benefits?

0 you work 30 or more hours per week?

 

Hours:

2 Date of hire/rehire: The first day the individual performs services for wages or any other form of compensation Is the Date of hire/rehire.

Anthem Siue Cross and Slue Shield is the trade name of Anthem Health Plans, inc. independent licensee of the Blue Cross end Blue Shield Assooiation.

‘LS450CTMENABS Rev. 2/17

ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Crass and Biue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

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SFE, aut DBe ae 0 0 1 4) a = iis 2) UR: sts
ale Ste i FulHtime: .| Name of recognized : ini .
B/) Sls Name(s) of person(s) Date-of birth pape Primary Care Physician {PCP)-came Current
=|a|/2 (Lastname, firstname, M1.) Sex (MM/DD/YYYY). sent age Araneae (Refer to provider directary-on-anthem.com), |° Patient?
Self 7 epee eos Name
SS SSE - Clyes
ooo Social Security no? (required) fity ONo
po Es {PCP no,
OlLegal spouse (Domestic partner Name Ua
OM toa = OYes
OOo Social Security no: (required) CF ee as city CNo
oo bi SS [PEP no.
Children up to age 26 or disabled dependents may be eligible. Please indicate if a child is a fulltime student and circle disabled dependents. 2
Dependent Name
Om 1 Clyes : Oyves
Goo Social Security no (required) OF JH] ++4+ 4 no City CINe
ot BG i PCP no.
Dependent : Name
_|OM Oyes , Dyes
' . . | i iu
OO Oi sccial Security no. <required) | CNe City ONo
5 | i PCP no.
Dependent Name
OM ; OYes , OYes
OOO Social Security no. (required) OF biti ONo city CNo
ro ty toe PCP no.

 

 

 

 

 

 

 

 

 

SEAM eC EL RSS errr
Do you or any other member of your family have any other medical, dental, or Anthem Blue Cross and Blue Shield (Anthem) coverage?
ClYes CINo _ ifyes, please complete the following.

“See

 

     

 

   

“Dependents:
Dae

 

- Spouse/Domestic Partner = = Sgr

 

 

Name of insurance company
Certificate (policy) no.
First and last date of coverage

 

 

 

 

 

Reason for termination

Section 8. Medicare/Medicaid information

Do you or any covered member have Medicare/Medicaid coverage? Have you or any covered member applied for Medicare/Medicaid disability?
CYes CINo Oyves CINc

Are you actively | Retirarient date | Health insurance} Medicare Part’A| Medicare Part 8 | Medicare P
Zcat work? <= | {MM/BDIYYYY) claimnas +) effective date |-effective date: effective date

Oyes CNo
OyYes CNo
Dyes CNo

 

 

 
 

 

 

            
 

 

 

 

 

 

 

 

 

 

 

SAU NCR eC eect UTC

For insurance entities, the term “medical loss ratio” refers to the ratio of incurred claims to earned premium for a prior calendar year. The MLR is calculated for
Managed care (HMO) and PPO/Indemnity plans, one for state law purposes and the other as determined under federal law. For 2015, Anthem’s Medical Loss Ratio
for state law purposes was 81.4% for HMO plans and 81.4% for PPO/indemnity plans. For 2015, Anthem's MLR for federal law purposes was 84.6% for small group
plans and 89.9% for large group plans,

| understand that intentionally false and/or intentionally incomplete responses or statements may result in rescission of coverage and/or non-payment of
claims for myself or my eligible dependents. | understand a copy of this application is provided to me as part of my Subscriber Agreement or health benefit
plan document as applicable and is incorporated by reference therein. | certify that my statements in this form are true and complete to the best of my
knowledge and belief. :

\'m signing here because | want to 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 | will make sure Anthem has
my most up to date email. These electronic communications may include specific details about me and my plan. | know [| can change my mind at any time or
request a free capy of specific materials by mail. I'll just contact Anthem to do either.

W-4 Certification Language: | certify each Social Security number listed on this application is correct.

Employee signature Print name Date (MM/DB/YYYY)

 

 

 

 

 

 

1 Anthem is required by the Internal Revenue Service to collect this information.
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