7. We, the employer, understand that Anthem and Anthem Blue Cross Life and Health Insurance Company standard process is to issue bills
(invoices) and accept premium payments online via the EmployerAccess system. We understand and agree that if we, the employer, need to opt-
out of online invoices and/or payments, we must send an email with “Opt-Out” in the subject line to employeraccesssupport@anthem.com and
provide the group number, contact name, email address, phone number and reason for opting out of the electronic billing and payment process.
8. If applicable, employer will receive on behalf of members, all notices delivered by Anthem, and immediately forward such notices to persons
involved, at their last known address.
9. We understand and agree that no coverage will be effective before the date determined by Anthem and/or Anthem Blue Cross Life and Health
Insurance Company, and that such coverage will be effective only if we have paid our first month’s premium and this application is accepted.
10. Life and Disability only: The advance premium check does not create temporary or interim insurance coverage and that receipt and deposit of
that payment does not guarantee issuance of insurance coverage. Rather, issuance of insurance coverage is expressly conditioned on Anthem
Blue Cross Life and Health Insurance Company’s determination that the group is an acceptable risk based on their current underwriting practices
and procedures. Unless these Conditions are met, there shall be no liability on the part of Anthem Blue Cross Life and Health Insurance
Company, except to refund the payment. The employer will be responsible for returning to individual employees any part of the payment
contributed by those employees.
11. That in order for Anthem to accept or decline this application, all the information requested on this application must be completed. In the event the
application is not complete, Anthem, or its designated agent(s), is authorized to obtain the necessary information and to complete that information
on this application. If the application is not complete, Anthem and/or Anthem Blue Cross Life and Health Insurance Company reserve(s) the right
to reject it and notify us in writing.
12. The employer understands that the coverage issued by Anthem Blue Cross Life and Health Insurance Company may be different than the
coverage applied for herein. In that event, Anthem Blue Cross Life and Health Insurance Company shall notify the employer of such differences,
and by payment of the appropriate premiums, the employer will accept the coverage as issued.
13. The premium rates calculated for the employer are contingent, based upon the accuracy of the eligibility data submitted on employees and
covered dependents to Anthem by the employer. Anthem reserves the right to review such rates upon receipt of all individual applications for
employers’ employees and to modify the rates, if the enrollment information so warrants. Any fraud or intentional misrepresentation of material
fact on the employees’ applications may, within the first 24 months following the issuance of the coverage, result in a material change to the
group’s coverage or premium rates as of the effective date of the group coverage.
14. The entire application for Group coverage has been reviewed, and all answers contained herein are true and complete to the best of the
employer’s and/or authorized representative’s knowledge and belief.
15. All employees applying for coverage are employees of the employer and receive salary or wages documented on state and/or federal payroll
reports. Eligible employees must work the required amount of hours per week, must be actively at work, have satisfied any applicable eligible
waiting period, and meet any other eligibility requirements for coverage.
16. The requested coverage is not in effect unless and until this application is approved by Anthem, that approval of coverage shall be evidenced by
issuing Group contracts and/or policies to the employer, and an employee’s coverage is not in effect unless and until the employee applies and is
approved for coverage by Anthem and/or Anthem Blue Cross Life and Health Insurance Company.
17. This small group off—exchange product is not eligible for a premium tax credit.
18. The HSA, which must be established for tax-advantaged treatment, is a separate arrangement between the individual and a bank or other
qualified institution. Applicant must be an “eligible individual” under IRS regulations to receive the HSA tax benefits. The IRS has not yet issued
HSA or high—deductible health plan regulations or determined that Anthem high-deductible plans are qualifying high-deductible health plans.
Consultation with a tax advisor is recommended.
19. If we decide to cancel our group coverage after coverage has been issued, we understand that the cancellation will become effective on the last
day of the month in which Anthem and/or Anthem Blue Cross Life and Health Insurance Company received the written notification of cancellation,
and that no premiums will be refunded for any period between Anthem’s receipt of the notification and the last day of the month when the
cancellation takes effect. If there are any premiums after the cancellation date, we understand that Anthem and/or Anthem Blue Cross Life and
Health Insurance Company will refund these premiums after 45 days from the premium deposit date.
20. We further understand and agree that we should keep prior coverage in force until notified of acceptance in writing by Anthem and/or Anthem
Blue Cross Life and Health Insurance Company and that no agent has the right to accept this application or bind coverage.
21. If this application is accepted, it becomes a part of our contract with Anthem and/or Anthem Blue Cross Life and Health Insurance Company.
22. That statements of medical history may be required of employees and dependents when applying for coverage within or outside the time frames
or amount of coverage limits established by Anthem Blue Cross Life and Health Insurance Company for life and disability insurance.
23. That life, accidental death and dismemberment, and disability claims filed by or on behalf of members may, at Anthem Blue Cross Life and Health
Insurance Company’s option, be suspended if premiums are not received timely.
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.
Employer tax ID no. (required): ________ _________ ________