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Health care plans offered by Anthem Blue Cross (Dickerson Insurance Services)

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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.
SG_OHIX_CA_EE 0121
CA_SG_EEAPP-A 01-21
Page 1 of 5
California Employee Enrollment Application
For Small Groups
Medical, Dental, Vision, Life and Disability
Health care plans offered by Anthem Blue Cross (Anthem). Insurance plans offered by Anthem Blue Cross Life and Health Insurance Company.
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. Note: Anthem is required by the Internal Revenue
Service and Centers for
Medicare & Medicaid (CMS) regulations to
collect Social Security
numbers.
Submit application to
your employer.
Please complete in black ink only.
Group/Case no. (if known)
Section A: Application Type — select one
New enrollment Open enrollment (not applicable for Life and Disability) Qualifying event (not applicable for Life and Disability)
COBRA/Cal-COBRA Rehire date (MM/DD/YYYY): ____/____ /_______
If you select Qualifying event or COBRA/Cal-COBRA, please select one event reason.
Marriage Birth of child Adoption of child Divorce or legal separation Death
COBRA Cal-COBRA — Cal-COBRA applicants must submit first month’s premium.
Involuntary loss of coverage — please explain (required): ______________________________________________________________________
Other — please explain (required): ________________________________________________________________________________________
Qualifying event or COBRA/Cal-COBRA date — Required (MM/DD/YYYY): ____/____ /_______
Section B: Employee Information
Last name
M.I.
Social Security no.
1
(required)
/ /
Home address - (P.O. Box not acceptable unless rural address)
City
State
ZIP code
County
Marital status
Single Married
Domestic Partner (DP)
Employment status
Full-time Part-time
Primary phone no.
Cell phone no.
Employer name
Occupation
Date of hire (MM/DD/YYYY)
/ /
Date of full-time employment (MM/DD/YYYY)
/ /
Date waiting period begins (MM/DD/YYYY)
/ /
No. of hours worked per
week
Language choice (optional): English (ENG) Spanish (SPA) Chinese (ZHO) Korean (KOR) Vietnamese (VIE) Tagalog (TGL)
Other (W09) — please specify: ___________________________________________________________________________________________
Do you read and write English? Yes No If no, the translator must sign and submit a Statement of Accountability/Translator’s Statement.
Employee email address:
For Medical plans
and all Dental Net DHMO plans offered by Anthem Blue Cross and regulated by the Department of Managed Health care.
I (primary applicant) agree to receive my plan-related communications for myself and any dependents, either by email or electronically. This may include
my certificate, evidence of coverage, explanation of benefits statements, required notices or helpful information to get the most out of my plan. I agree to
provide an update Anthem with my current email address. I know that at any time I can change my mind and request a copy of these materials (or any
specific materials) by mail, by contacting Anthem. I (or my enrolled dependents) will update our communication preferences by going to anthem.com/ca
or calling Member Services at 1-855-383-7248.
For Dental PPO, Vision, Life and Disability plans
offered by Anthem Blue Cross Life and Health Insurance Company and regulated by the California
Department of Insurance, Anthem will deliver plan materials and related items by mail.
1 Anthem is required by the Internal Revenue Service and Centers for Medicare & Medicaid (CMS) regulations to collect this information.
click to sign
signature
click to edit
Social Security no.
1
: ______/_____/________
SG_OHIX_CA_EE 0121
CA_SG_EEAPP-A 01-21
Page 2 of 5
Section C: Type of Coverage —Your employer will advise you of your plan options and contract codes.
1. Medical Coverage
Please Note: All health plans
2
include the required coverage for the dental and vision pediatric essential health benefits.
Medical plan name:
______________________________________________________
Contract code, if known: ______________________
Member medical coverage – select one: Employee only Employee + Spouse/Domestic Partner Employee + Child(ren) Family
2. Dental Coverage
Anthem Dental HMO
2
and Dental PPO
3
plans do not include certified pediatric dental essential health benefits.
Member dental coverage - select one: Employee only Employee + Spouse/Domestic Partner Employee + Child(ren) Family
Dental plan name:
______________________________________________________
Contract code, if known: ______________________
3. Vision Coverage
These optional vision plans
3
do not include coverage for vision pediatric essential health benefits.
Member vision coverage - select one: Employee only Employee + Spouse/Domestic Partner Employee + Child(ren) Family
Vision plan name:
______________________________________________________
Contract code, if known: ______________________
4. Life
3
, Accidental Death & Dismemberment
3
(AD&D), and Disability
3
Coverage
Basic Life & AD&D Basic Dependent Life
Supplemental/Voluntary Life and AD&D
Supplemental/Voluntary Dependent Life Spouse/DP
Supplemental/Voluntary Dependent Life Child
$ _________ (Employee amount)
$ _________ (Spouse/DP amount)
$ _________ (Child amount)
Short Term Disability
Long Term Disability
Voluntary Short Term Disability
Voluntary Long Term Disability
Current annual income: $
Life and Disability class no.:
Total percentages must add up to 100%. If no percentages are indicated, the proceeds will be divided equally. If no primary beneficiary survives, the
proceeds will be paid to the contingent beneficiary(ies) listed above. Beneficiaries may be changed by the insured’s written notice to his or her employer.
Beneficiary designation — Attach a separate sheet if necessary.
Name of beneficiary
Percentage
Social Security no.
Relationship to applicant
Age
Primary
Contingent
Primary
Contingent
Primary
Contingent
Primary
Contingent
Primary
Contingent
Primary
Contingent
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.
Authorization
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.
In CA, NV, and WA, Spouse also includes your registered Domestic Partner.
Spouse signature
X
Spouse name
Date (MM/DD/YYYY)
/ /
If an applicant's age at the time of application is 15, the applicant must submit a written statement, signed by the parent, consenting to the
minor's application for coverage.
Incomplete applications will be mailed back to you for completion. This may delay the effective date of your coverage.
1 Anthem is required by the Internal Revenue Service and Centers for Medicare & Medicaid (CMS) regulations to collect this information.
2 These plans are offered by Anthem Blue Cross and regulated by the Department of Managed Health Care.
3 Dental PPO, Vision, and Life and Disability plans are offered by Anthem Blue Cross Life and Health Insurance Company and regulated by the
California Department of Insurance.
Social Security no.
1
: ______/_____/________
SG_OHIX_CA_EE 0121
CA_SG_EEAPP-A 01-21
Page 3 of 5
Section D: Family Information —Complete this section for yourself and all dependents. All fields required. Attach a separate sheet if necessary.
Please access Find a Doctor at anthem.com/ca to determine if your physician is a participating provider.
For HMO plans: provide 3- or 6- digit Primary Care Physician no.
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, children for whom you’ve assumed a parent-child relationship
2
(not including foster children) or your
spouse or domestic partner’s children (to the end of the calendar month in which they turn age 26). In the case of your child, the age limit of 26 does
not apply when the child is and continues to be (1) incapable of self-sustaining employment by reason of a physically or mentally disabling injury,
illness, or condition and (2) chiefly dependent upon the subscriber for support and maintenance. The employee will be required to submit certification
by a physician of the child’s condition. List all dependents beginning with the eldest.
Employee last name
First name
M.I.
Sex
Male Female
Birthdate (MM/DD/YYYY)
/ /
Primary Care Physician (PCP) name (if selecting an HMO)
PCP ID no. (HMO only)
Existing patient
Yes No
Primary Care Dentist (PCD) name (If selecting Dental net DHMO plan)
PCD ID no.
Existing patient
Yes No
Spouse/Domestic Partner last name
First name
M.I.
Social Security no.
1
(required)
/ /
Sex
Male Female
Birthdate (MM/DD/YYYY)
/ /
Relationship to applicant
Spouse Domestic Partner
PCP name (if selecting an HMO plan)
PCP ID no. (HMO only)
Existing patient
Yes No
PCD name (If selecting Dental net DHMO plan)
PCD ID no
Existing patient
Yes No
Does this dependent have a different address? Yes No
If yes, full address and ZIP code: _______________________________________________________
Dependent last name
First name
M.I.
Social Security no.
1
(required)
/ /
/ /
Sex
Male Female
Birthdate (MM/DD/YYYY)
/ /
Relationship to applicant
Child Other
3
If other, what is relationship?______________
PCP name (if selecting an HMO plan)
PCP ID no. (HMO only)
Existing patient
Yes No
PCD name (If selecting Dental net DHMO plan)
PCD ID no
Existing patient
Yes No
Does this dependent have a different address? Yes No
If yes, full address and ZIP code: _______________________________________________________
Dependent last name
First name
M.I.
Social Security no.
1
(required)
/ /
Sex
Male Female
Birthdate (MM/DD/YYYY)
/ /
Relationship to applicant
Child Other
3
If other, what is relationship?______________
PCP name (if selecting an HMO plan)
PCP ID no. (HMO only)
Existing patient
Yes No
PCD name (If selecting Dental net DHMO plan)
PCD ID no
Existing patient
Yes No
Does this dependent have a different address? Yes No
If yes, full address and ZIP code: _______________________________________________________
1 Anthem is required by the Internal Revenue Service and Centers for Medicare & Medicaid (CMS) regulations to collect this information.
2 As defined in 2 CCR § 599.500(o).
3 Eligibility subject to Evidence of Coverage.
Social Security no.
1
: ______/_____/________
SG_OHIX_CA_EE 0121
CA_SG_EEAPP-A 01-21
Page 4 of 5
Section E: Prior and Other Coverage
1. Is anyone applying for coverage currently eligible for Medicare? Yes No If yes, give name:_____________________________
Medicare ID no.
Part A effective date (MM/DD/YYYY)
/ /
Part B effective date (MM/DD/YYYY)
/ /
Medicare Part D ID no.
Medicare Part D Carrier
Part D effective date (MM/DD/YYYY)
/ /
2. Does anyone on this application intend to continue other coverage if this application is accepted? Yes No
3. Is anyone applying for coverage covered by other health, dental, or orthodontia coverage? Yes No
4. On the day your coverage begins, will you or a family member be covered by other dental coverage? Yes No
If yes to any of these questions, please provide the following:
Name of person covered
(Last name, first, M.I.)
Type
(select one)
Coverage (select
all that apply)
Carrier name
Policy ID no.
Dates (if applicable)
(MM/DD/YYYY)
Individual Group
Medicare
Health Dental
Orthodontia
Start: ___ /___ /___
End: ___ /___ /___
Individual Group
Medicare
Health Dental
Orthodontia
Start: ___ /___ /___
End: ___ /___ /___
Individual Group
Medicare
Health Dental
Orthodontia
Start: ___ /___ /___
End: ___ /___ /___
Individual Group
Medicare
Health Dental
Orthodontia
Start: ___ /___ /___
End: ___ /___ /___
Section F: Waiver/Declining Coverage — Proof of coverage may be required. (Proof of coverage not applicable for Life and Disability.)
Type of coverage/Declined for: Select all that apply.
Reason for declining/refusing coverage: Select all that apply.
Employee
Medical Dental Vision
Life/AD&D Short Term Disability
Long Term Disability
No coverage
Covered by Spouse’s/Domestic Partner’s group coverage
Spouse/Domestic Partner covered by their employer’s
group coverage.
Enrolled in Individual coverage
Medicare/Medi-Cal/VA
Enrolled in other Insurance — Please provide company
name and plan:_________________________________
Other — please explain
__________________________
Spouse/
Domestic Partner
Medical Dental Vision Dependent Life
Dependent(s)
Medical Dental Vision Dependent Life
List name of dependents to be waived: _______________
I acknowledge that the available coverages have been explained to me by my employer and I know that I have every right to apply for coverage. I have
been given the chance to apply for this coverage and I have decided not to enroll myself and/or my dependent(s), if any. I have made this decision
voluntarily, and no one, including but not limited to my employer, agent or life carrier, has tried to influence me or put any pressure on me to waive
coverage. BY WAIVING THIS GROUP MEDICAL, DENTAL, VISION, DISABILITY OR LIFE COVERAGE (UNLESS EMPLOYEE AND/OR
DEPENDENTS HAVE GROUP MEDICAL, DENTAL, VISION, DISABILITY OR LIFE COVERAGE ELSEWHERE) I ACKNOWLEDGE THAT MY
DEPENDENTS AND I MAY HAVE TO WAIT UNTIL THE NEXT OPEN ENROLLMENT TO BE ENROLLED IN THIS GROUP‘S MEDICAL, DENTAL,
OR VISION PLAN UNLESS I QUALIFY FOR A SPECIAL OPEN ENROLLMENT. I also understand that if I wish to apply for Life coverage in the future,
I may be required to provide evidence of insurability at my expense. Please note Spouse/Domestic Partner and Dependent coverage will not be
available if the Employee has waived/declined.
Special Open Enrollment (Not applicable to Life or Disability.
If you declined enrollment for yourself or your dependent(s) (including a spouse/domestic partner), you may be able to enroll yourself or your
dependent(s) in this health benefit plan or change health benefit plans as a result of certain triggering events, including: (1) you or your dependent loses
minimum essential coverage; (2) you gain or become a dependent; (3) you are mandated to be covered as a dependent pursuant to a valid state or
federal court order; (4) you have been released from incarceration; (5) your health coverage issuer substantially violated a material provision of the
health coverage contract; (6) you gain access to new health benefit plans as a result of a permanent move; (7) you were receiving services from a
contracting provider under another health benefit plan, for one of the conditions described in Section 1373.96(c) of the Health and Safety Code and that
provider is no longer participating in the health benefit plan; (8) you are a member of the reserve forces of the United States military or a member of the
California National Guard, and returning from active duty service; or (9) you demonstrate to the department that you did not enroll in a health benefit
plan during the immediately preceding enrollment period because you were misinformed that you were covered under minimum essential coverage.
You must request special enrollment within 60 days from the date of the triggering event to be able to enroll yourself or your dependent(s) in this health
benefit plan or change health benefit plans as a result of a qualifying triggering event.
Sign here only if you are declining coverage for yourself or dependents.
Signature of applicant
X
Printed name
Date (MM/DD/YYYY)
/ /
1 Anthem is required by the Internal Revenue Service and Centers for Medicare & Medicaid (CMS) to collect this information.
Social Security no.
1
: ______/_____/________
SG_OHIX_CA_EE 0121
CA_SG_EEAPP-A 01-21
Page 5 of 5
Section G: Terms, Conditions and Authorizations — Please read this section carefully before signing the application.
As an eligible employee, I am requesting coverage for myself and all eligible dependents listed and authorize my employer to deduct any required
contributions for this insurance from my earnings. To the best of my knowledge or belief, all statements and answers I have given are true and
complete. I understand it is a crime to make or cause to be made a knowingly false or fraudulent material statement or material representation to an
insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. I
understand all benefits are subject to conditions stated in the Group Contract and coverage document.
In signing this application I represent that:
I have read or have had read to me the completed application, and I realize any acts of fraud or intentional misrepresentation of material fact in the
application may result in loss of coverage within 24 months following the issuance of the coverage.
I certify each Social Security number listed on this application is correct.
I understand that I may not assign any payment under my Anthem Blue Cross (Anthem) program. I agree to have money taken from my wages, if
necessary, to cover the premium cost for the coverage applied for.
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 or sold case coverage documents.
I understand that, to the extent allowed by law, Anthem reserves the right to accept or decline this application for coverage (and that Anthem Blue Cross
Life and Health Insurance Company may accept only certain people or terms for coverage), and that no right is created by my application for coverage.
I also understand that I may not be covered for pre-existing conditions for Long Term Disability and Short Term Disability, if applicable. (See the
policy/certificate for important information).
I agree that I will let my employer know right away of any changes that would make me or any dependent(s) ineligible for this coverage.
I understand that coverages will become effective on the date established by the provisions of the group policy, contract and certificates issued
thereunder.
By signing this application, I agree to the taping or monitoring of any phone calls between Anthem and myself.
For Health Savings Account enrollees: I authorize the Health Savings Account (HSA) financial custodian (provided I am enrolling in an HSA) to
provide Anthem with information about my HSA, including account number, account balance and information regarding account activity. I understand
that my authorization is required before the financial custodian may provide Anthem with information regarding my HSA and that I may provide Anthem
with a written request to revoke my authorization at any time.
If applying for Life and/or Disability insurance, I represent that I have read and agree to the terms in the Life and Disability Coverage in Section 4,
above.
HIV TESTING PROHIBITED: California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining
health insurance.
Read carefully — Signature required
REQUIREMENT FOR BINDING ARBITRATION (Not applicable to Life and Disability coverage.)
ALL DISPUTES BETWEEN YOU AND ANTHEM BLUE CROSS AND/OR ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY,
INCLUDING BUT NOT LIMITED TO DISPUTES RELATING TO THE DELIVERY OF SERVICE UNDER THE PLAN/POLICY OR ANY OTHER
ISSUES RELATED TO THE PLAN/POLICY AND CLAIMS OF MEDICAL MALPRACTICE, MUST BE RESOLVED BY BINDING ARBITRATION, IF
THE AMOUNT IN DISPUTE EXCEEDS THE JURISDICTIONAL LIMIT OF SMALL CLAIMS COURT AND THE DISPUTE CAN BE SUBMITTED TO
BINDING ARBITRATION UNDER APPLICABLE FEDERAL AND STATE LAW, INCLUDING BUT NOT LIMITED TO, THE PATIENT PROTECTION
AND AFFORDABLE CARE ACT. California Health and Safety Code Section 1363.1 and Insurance Code Section 10123.19 require specified
disclosures in this regard, including the following notice: It is understood that any dispute as to medical malpractice, that is as to whether
any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently
rendered, will be determined by submission to arbitration as permitted and provided by federal and California law, including but not limited
to, the Patient Protection and Affordable Care Act, and not by a lawsuit or resort to court process except as California law provides for
judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any
such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. YOU AND ANTHEM BLUE CROSS
AND/OR ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY AGREE TO BE BOUND BY THIS ARBITRATION PROVISION.
YOU ACKNOWLEDGE THAT FOR DISPUTES THAT ARE SUBJECT TO ARBITRATION UNDER STATE OR FEDERAL LAW THE RIGHT TO A
JURY TRIAL, THE RIGHT TO A BENCH TRIAL UNDER CALIFORNIA BUSINESS AND PROFESSIONS CODE SECTION 17200, AND/OR THE
RIGHT TO ASSERT AND/OR PARTICIPATE IN A CLASS ACTION ARE ALL WAIVED BY YOU. This agreement does not limit your rights to
internal and external review of adverse benefit determinations as required by 45 CFR 147.136. Enforcement of this arbitration clause,
including the waiver of class actions, shall be determined under the Federal Arbitration Act (“FAA”), including the FAA’s preemptive effect
on state law. By signing, writing or typing your name below you agree to the terms of this agreement and acknowledge that your signed,
written or typed name is a valid and binding signature.
Sign
here
Applicant Signature
X
Date (MM/DD/YYYY)
/ /
1 Anthem is required by the Internal Revenue Service and Centers for Medicare & Medicaid (CMS) to collect this information.
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Health care plans offered by Anthem Blue Cross (Dickerson Insurance Services)

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Completed 1 June 2021

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