Fillable Conditions of Enrollment Start-Up Companies/PEO Spin-Off Groups (Dickerson Insurance Services)

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Conditions of Enrollment Start-Up Companies/PEO Spin-Off Groups (Dickerson Insurance Services)

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Conditions of Enrollment
Start-Up Companies/PEO Spin-Off Groups
anthem.com/ca
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
12378CAEENABC Rev. 8/18
3287300 12378CAEENABC Conditions of Enrollment Prt FR 08 18
Company name
Part A: Start–up companies
I agree that if, after review, Anthem Blue Cross (Anthem) or its affiliates offers my group coverage, I will provide the company’s first 30 days’
complete payroll records for all employees within 45 days of the effective date.
I understand that Anthem or its affiliates reserve the right to not renew coverage for my group if it does not meet Anthem’s criteria as outlined
in the Group Benefit Agreement and/or Group Contract in the “Obligations of Employers” section.
By signing below, I agree to the above conditions of enrollment in addition to all other terms, limitations and conditions of the Group Benefit
Agreement and/or Group Contract.
Company officer signature
X
Company officer name (please print)
Company officer title Date (MM/DD/YYYY)
Part B: PEO spin–off groups
I certify that the company has canceled its contract with the PEO effective: (MM/DD/YYYY)
I agree that if, after review, Anthem or its affiliates offers my group coverage, I will provide the company’s first 30 days’ complete payroll records
for all employees within 45 days of the effective date.
I understand that Anthem or its affiliates reserve the right to not renew coverage for my group if it does not meet Anthem’s criteria as outlined
in the Group Benefit Agreement and/or Group Contract in the “Obligations of Employers” section.
By signing below, I agree to the above conditions of enrollment in addition to all other terms, limitations and conditions of the Group Benefit
Agreement and/or Group Contract.
Company officer signature
X
Company officer name (please print)
Company officer title Date (MM/DD/YYYY)
Small Group Services
P.O. Box 9042
Oxnard, CA 93031-9042
1-855-239-9251
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Conditions of Enrollment Start-Up CompaniesPEO Spin-Off Groups (Dickerson Insurance Services)

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Completed 1 June 2021

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