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

Fill Online, Printable, Fillable, Blank Health care plans offered by Anthem Blue Cross (Dickerson Insurance Services) Form

Use Fill to complete blank online DICKERSON INSURANCE SERVICES pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

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

On average this form takes 81 minutes to complete

The Health care plans offered by Anthem Blue Cross (Dickerson Insurance Services) form is 8 pages long and contains:

  • 0 signatures
  • 21 check-boxes
  • 316 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Dickerson Insurance Services forms online.

BROWSE DICKERSON INSURANCE SERVICES FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
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_ER 0121
CA_SG_ERAPP-A 01-21
Page 1 of 8
California Employer 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 employer, 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 the application.
Note: Employer Tax ID Numbers are required under Centers for Medicare & Medicaid Services (CMS) regulations.
Please complete in black ink only.
Section A: Application Type
New enrollment Change(s)
Group/Case no.(if known)
Section B: Company Information
Legal Company name
Employer tax ID no. (required)
Doing Business As (DBA)(if applicable)
County
Company street address (principal business address¹)
City
State
ZIP code
Billing address- If different from above
City
State
ZIP code
Is this for coverage as a member of an association plan? Yes No If yes, association name: __________________________________
Organization type: Corporation Partnership Proprietorship
Limited Liability Company (LLC) Limited Partnership (LP) Limited Liability
Partnership (LLP) Other: _______________________________________________________________________
SIC code - required
Type of business (be specific)
Date business established (MM/DD/YYYY)
/ /
Company contact name
Title
Primary phone no.
Company’s primary contact email address
Additional company contact name
Title
Additional company contact email address
Applies only to Medical plans and Dental Net DHMO plans offered by Anthem Blue Cross and regulated by the Department of Managed Health Care.
We, the employer, agree that Anthem can deliver plan materials and related items, including but not limited to benefit booklets, summaries, billing
statements, notices of nonpayment and cancellation and other notices, via the company’s primary contact email address indicated above or other
electronic means as permitted by law. We agree that we will provide an update Anthem with a current email address. We understand that at any time we
can change our decision and request a free copy of these materials (or any specific materials) by mail or by contacting Anthem at 1-855-854-1429.
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 The principal business address means the principal business address registered with the State or, if a principal business address is not registered with
the State, or is registered solely for purposes of service of process and is not a substantial worksite for the policyholder's business, the business address
within the State where the greatest number of employees of such policyholder works. If, for a network plan, the group policyholder's principal business
address is not within the service area of such plan, and the policyholder has employees who live, reside, or work within the service area, the principal
business address for purposes of the network plan is the business address within the plan's service area where the greatest number of employees work
as of the beginning of the plan year. If there is no such business address, the rating area for purposes of the network plan is the rating area that reflects
where the greatest number of employees within the plan's service area live or reside as of the beginning of the plan year.
Employer tax ID no. (required): ________ _________ ________
`
SG_OHIX_CA_ER 0121
CA_SG_ERAPP-A 01-21
Page 2 of 8
Do you want to enroll in Premium Only Plan (P.O.P.)? Yes No P.O.P. is a payroll administration service offered by Wage Works, Inc
(an independent company not affiliated with Anthem) that helps companies receive Internal Revenue Service (IRS) Section 125 tax advantages.
If you choose to enroll, download the P.O.P. application at www.anthem.com/easyrenew and complete.
Do you have any affiliates that qualify as a single employer under subsection (b), (c), (m) or (o) of Internal Revenue Code Section 414?
Yes No If yes, please give the legal names, federal tax ID no. and the number of employees employed by each.
Legal name
Federal tax ID no.
No. of employees employed
Section C: Ownership
Please account for 100% of the ownership, regardless of eligibility. Insert an additional sheet if necessary.
Last name
First name
M.I.
Percentage of
ownership
Eligible
Yes No
Yes No
Yes No
Section D: Type of Coverage
1. Medical Coverage Medical plans offered by Anthem Blue Cross.
Please Note: All health plans include the required coverage for the dental and vision pediatric essential health benefits.
Step 1 – Select a network or networks .
You may choose one PPO,
Step 2 – Please indicate one or more plan(s) designs you would like to offer to your employees, within the
network(s) you selected.
Insert an additional sheet if necessary.
PPO: Prudent Buyer PPO
Select PPO
HMO: CaliforniaCare HMO
Select HMO
Priority Select HMO
Medical plan name
Contract code
Required for Consumer-Driven Health Plans (CDHP) — Only one choice is allowed.
We request Anthem to facilitate opening a Health Savings Account (HSA) with its service provider for our employees. We understand a completed
CDHP questionnaire is required in order to open the HSA account. In doing so, we agree for Anthem to disclose our member’s data to its banking
service provider.
Group will facilitate its own non-Anthem Health Savings Account (HSA).
Riders/Optional Benefits – Select additional optional benefits.
Please note: All subscribers and their dependents will be enrolled with the rider benefits if selected. Additional premium may apply.
Infertility Benefits Women’s Contraceptive Opt-out Benefits — Submit the Religious Self-Certification Form. The form can be found on the
www.anthem.com/easyrenew site.
Choose your medical contribution for each month – only one choice is allowed.
Contribution option 1: Traditional option – We will contribute (50% to 100%) ______% per employee ______% per dependent (optional)
Contribution option 2: Fixed Dollar Option – We will contribute (at least $100 in $5 increments): $______________________________
Contribution option 3: Percentage of plan option – We will contribute (50% to 100%): ______% to the following plan_____________________________
and/or one HMO network.
EPO: Prudent Buyer PPO
one EPO
__
Note: PPO and EPO plans — Prudent Buyer PPO and Select PPO network plans can only be offered alongside other plans with the same network
type. (For example, plans on the Select P
PO network can be offered alongside other plans on the Select P
PO network, but they cannot be offered
alongside plans on the Prudent Buyer PPO network (PPO and EPO plans). Not all network options are available in every area.)
HMO plans — CaliforniaCare HMO, Select HMO, and Priority Select HMO network plans can only be offered alongside other plans with the same
network type. (For example, plans on the Select HMO network can be offered alongside other plans on the Select HMO network, but they cannot be
offered alongside any other HMO network. Not all network options are available in every area.)
SG_OHIX_CA_ER 0121
CA_SG_ERAPP-A 01-21
Page 3 of 8
Dental HMO
1
and Dental PPO
2, 4
plans do not include dental pediatric essential health benefits.
Employer sponsored
Voluntary
3
Dental plan name
Contract code
Optional: Choose your dental contribution for each month. We will contribute: ______% per employee ______% per dependent)
Is this plan intended to replace any existing group dental coverage? Yes No
If yes, please complete the information in section G for each group dental insurance plan you now have.
3. Vision Coverage
2
— Employer-sponsored plans (available for 2–100 Employee Small Groups, a minimum of two subscr
ibers must enroll.)
Voluntary Vision plans (available for 5–100 Employee Small Groups, a minimum of five subscribers must enroll.)
Vision plans do not include vision pediatric essential health benefits
Employer sponsored
Voluntary
Vision plan name
Contract code
Optional: Choose your vision contribution for each month. We will contribute: ______% per employee ______% per dependent)
4. Life
2
, Accidental Death & Dismemberment (AD&D)
2
, and Disability
2
Coverage -
A minimum of two employees must enroll unless otherwise noted.
All plan selections must be accompanied by a Life and/or Disability quote.
Life/AD&D products
Select Life products and group contribution percentage:
Contribution
percentage
Disability products
Select products
and group contribution percentage:
Contribution
percentage
Flat Basic Life & AD&D Amount: _______
Salary Basic Life & AD&D
Salary multiplier:
1x salary
2x salary
3x salary
Basic Dependent Life Up to 50% of employee life amount
$5,000 Spouse/Domestic Partner/$2,500 child
$10,000 Spouse/Domestic Partner/$5,000 child
$20,000 Spouse/Domestic Partner/$10,000 child**
Supplemental/Voluntary Life and AD&D**
Supplemental/Voluntary Dependent Life**
**Available for Groups of 10+ eligible employees
______%
______%
______%
Short Term Disability
Flat Amount $________
 Salary based _______%
Long Term Disability
Voluntary Short Term Disability**
 Flat Amount $________
Salary based _______%
Voluntary Long Term Disability**
**Available for Groups of 10+ eligible employees
______%
______%
Age band rate changes and Life reductions in coverage due to age: First of the
month following date of birth Group anniversary
If you are applying for disability coverage and the contribution percentage shown above is less than 100%, it is required to
indicate whether
employee disability premiums are on a pre or post -post-tax basis. If it varies by class, attach a separate sheet with details by class.
Short Term Disability Long Term Disability Voluntary Short Term Disability
Voluntary Long Term Disability
Pre Tax Post Tax Pre Tax Post Tax Pre Tax
Post Tax Pre Tax Post Tax
Short Term Disability plans and benefits elected above do not replace state-mandated disability
benefits. If you want Anthem to be your state-mandated
disability/paid family leave carrier an additional application and proposal are required.
Contact your broker for more information.
Is the eligibility waiting period for new eligible employees enrolling in Life/AD&D and/or Disability plans after the group’s coverage effective date the
same as the Anthem medical policy waiting period?
Yes
No If no, enter the Life and Disability eligibility waiting period below.
If you offer more than two classes of eligible employee please attach a separate sheet with details.
Class
number
Coverage description
(Ex. Life, Short Term Disability, Long Term Disability,
etc.)
Description of eligibility waiting period
(Ex. Date of hire, First of
the month following 60
days of continuous employment, etc.)
Pre or Post Tax
(for Disability plans)
An employee not actively at work on the Life, AD&D, or Disability policy effective date or
the employee’s eligibility date will not be covered until such
employee returns to active work.
1 Offered by Anthem Blue Cross.
2 Offered by Anthem Blue Cross Life and Health Insurance Company.
3 Not available in conjunction with the employer-sponsored Dental HMO and Dental PPO plans
.
4 Orthodontia coverage is only available for groups with five or more enrolled employees
.
Employer tax ID no. (required): ________ _________ ________
`
__
2. Dental Coverage — Employer-sponsored plans (available for 2–100 Employee Small Groups, a minimum of two subscribers must enroll.)
Voluntary Dental plans
3
(available for 5–100 Employee Small Groups, a minimum of five subscribers must enroll.)
2. Dental Coverage — Employer-sponsored plans (available for 2–100 Employee Small Groups, a minimum of two subscribers must enroll.)
Voluntary Dental plans
3
(available for 5–100 Employee Small Groups, a minimum of five subscribers must enroll.)
SG_OHIX_CA_ER 0121
CA_SG_ERAPP-A 01-21
Page 4 of 8
Section E: Eligibility
1. Does your group meet the definition of a small employer,
as defined under applicable law?
1
Yes No
2. Total number of employees
(including employed owners/officers): _______
3. Number of eligible full—time employees
2
(minimum 30 hours per week): _______
4. Number of part-time employees
2
: _______
Are permanent employees who work between
20-29 hours weekly to be covered?
3
Yes No
If yes, number of eligible part-time enrollees: _______
5. Number of employees enrolling in:
Medical: _______ Dental: _______ Vision: _______
Life: _______ Disability: _______
6. Number of eligible DECLINING employees: _______
7. Number of INELIGIBLE employees: _______
8. Waiting period for new employees:
First of the month after hire date
First of the month following one month from the date of hire
First of the month following two months from date of hire, not to
exceed 90 days
9. Does your business have additional employees
in another state? Yes No
If yes, specify state: _____________________________________
How many employees reside in CA: _______
How many employees reside in another state: _______
10. Is your group currently subject to Cal-COBRA? Yes No
(Employed 2–19 eligible employees on at least 50% of its working
days in the previous calendar year; or if not in business during any
part of the previous calendar year employed 2–19 eligible employees
on at least 50% of its working days during the previous calendar
quarter; and not subject to COBRA).
California law also requires plans to offer an enrollee who has
exhausted continuation coverage under COBRA the opportunity to
continue coverage for up to 36 months from the date the enrollee’s
continuation coverage began. If the enrollee is entitled to less than 36
months of continuation coverage under COBRA.
Number of Cal-COBRA enrollees: __________
11. Is your group currently subject to COBRA? Yes No
(Employed 20 or more total employees on at least 50% of the working
days in the previous calendar year)?
Number of COBRA enrollees: __________
12. Under the Medicare Secondary Payer rules, which one applies for
your group?
Medicare is primary (less than 20 employees)
Anthem is primary (20 or more employees)
Medicare is primary coverage for groups with less than 20 employees;
Anthem is primary coverage for groups with 20 or more total
employees on each working day in each of 20 or more calendar
weeks in the current calendar year or the preceding calendar year.
13. Is your group currently subject to the Family Medical
Leave Act of
1993 (50 or more total employees)? Yes No
Section F: Leave of Absence
Medical: Number of months employees are eligible to continue group coverage while on an employer—approved temporary medical leave of
absence. None 1 month 2 months 3 months 4 months 5 months 6 months
Personal: Number of months employees are eligible to continue group coverage while on an employer—approved temporary personal leave of
absence. None 1 month 2 months 3 months
Section G: Prior Coverage
Has this group had coverage within 12 months of this application’s signature date? Yes No
Will this plan replace current
If yes, carrier name
Termination Date
(MM/DD/YYYY)
Medical coverage
Yes No
/ /
Vision coverage
Yes No
/ /
Life/AD&D coverage
Yes No
/ /
Supplemental/Voluntary Life
Yes No
/ /
Disability coverage
Yes No
/ /
Dental coverage
Yes No
Carrier name
Type of Plan (DHMO, EPO, PPO)
Effective Date
/ /
/ /
Employer tax ID no. (required): ________ _________ ________
`
__
1 For plan years commencing on or after January 1, 2016, a small employer is defined as an employer employing an average of at least 1 but no more
than 100 full—time, including full—time equivalent, employees during the preceding calendar quarter or preceding calendar year and who employs at
least 1 employee on the first day of the plan year. For purposes of determining employer eligibility in the small employer market, California adopted the
federal method for counting full-time employees and full-time—equivalent employees. For specific guidance concerning the Affordable Care Act, the
Internal Revenue Code or California State laws or regulations, you should consult with your attorney, Certified Public Accountant or other authorized
consultant or advisor.
2 The following do not qualify as an employee for purposes of group eligibility: (1) an individual that wholly owns the above—named company on his/her
own or with his/her spouse/domestic partner; (2) the spouses/domestic partner of sole proprietors; (3) partners of a partnership and their
spouses/domestic partner; (4) a 2-percent S corporation shareholder; (5) a worker described in Section 3508 of Title 26, Internal Revenue Code.; or (6)
a leased employees (as defined in 26 U.S.C. § 414(n)(2)).
3 Not applicable to Life and Disability.
SG_OHIX_CA_ER 0121
CA_SG_ERAPP-A 01-21
Page 5 of 8
Section H: Cal-COBRA/COBRA/FMLA Questionnaire — If additional space is needed to include all applicable employees, please use a photocopy of
this page.
Complete for each employee or family member currently on Cal—COBRA or COBRA or FMLA
Cal—COBRA: Complete for each employee terminated in the last 60 days who has had a qualifying event.
COBRA: Complete for each employee terminated in the last 90 days who has had a qualifying event.
FMLA: Complete for each employee on family or medical leave Insert an additional sheet if necessary. The Family and Medical Leave Act of 1993
requires groups with 50 or more employees to provide up to 12 weeks of unpaid, job-protected leave to “eligible” employees for certain family
and medical reasons.
Insert an additional sheet if necessary.
Last name
First name
MI
DOB
Social Security No.
1
Cal-COBRA
COBRA
FMLA
Beginning date of leave or date of qualifying event
Describe qualifying event:
To the best of your knowledge, will this employee/dependent exercise their Cal—COBRA/COBRA option? Yes No
To the best of your knowledge, will this employee return to work? Yes No
Section I: Access of Group Information by designated agent, producer, broker, agency, brokerage, and/or general agency
We the employer hereby authorize our designated agent, producer, broker, agency, brokerage, general agency, and their respective employees
currently on file with Anthem (Agent) to access our health plan information, including protected health information, on behalf of our health plan through
Anthem’s EmployerAccess system or any other access points Anthem may offer. This information may include, but is not limited to, detail about
members, plan selections and bills/invoices. Our Agent is also authorized to make changes to our information on our behalf, including but not limited to
adding/deleting plans and members and changing member demographic information. We will be responsible for the activities of our Agent. If our
Agent on file changes, these authorizations will apply with respect to our successor Agent. Our Agent is required to maintain original documentation
and will make such documentation available to Anthem upon request.
Select this box ONLY if the employer DOES NOT want to authorize the agent, producer, broker, agency, brokerage, general agency, and their
respective employees currently on file with Anthem (Agent) to access and change the group’s information on behalf of the group. Do not select this
box if you consent.
Section J: General Agreements — Please read this section carefully before signing the application.
The standard open enrollment period is at least 31 days before the group’s renewal date and 31 days after, no more often than once in any 12
consecutive months. The open enrollment period does not apply to life and disability products.
Please select the box that applies:
We, the employer, as administrator of an Employee Welfare Benefit Plan under ERISA (Employee Retirement Income Security Act of 1974), apply to
obtain the coverage indicated on this application. We understand that any dispute involving an adverse benefit decision may be subject to voluntary
binding arbitration only after the ERISA appeals procedure has been completed.
We, the employer, as administrator of an Employee Welfare Benefit Plan which is a church plan or governmental plan as defined under ERISA
(Employee Retirement Income Security Act of 1974) and therefore not subject to ERISA, apply to obtain the coverage indicated on this application.
Employer, through its authorized representative below, understands and certifies, and, if approved for coverage and by payment of premiums, agrees to
the following:
1. To comply with all terms and provisions of the Group Contract(s) issued, and trust agreements, if applicable, and also accepts enrollment under
the Anthem Blue Cross (Anthem) and/or Anthem Blue Cross Life and Health Insurance Company trust policy(ies), if applicable.
2. To make the coverage available to all eligible employees and their eligible dependents and to distribute information and documents to enrolled
employees as needed.
3. To maintain records and furnish to Anthem or their designated agent(s), any information required in connection with administration of the
coverage. Original source documents, including but not limited to employee/member enrollment documentation, shall be available upon Anthem’s
request.
4. For the purpose of clinical outreach, we the Employer agree that the cell phone numbers provided in the electronic enrollment files have been
freely provided by the employee and have not been obtained by a look up service or third party. Anthem will honor Do Not Call requests for all
telephone numbers collected.
5. To provide notice of applicable conversion rights and rights to continue health coverage under COBRA to eligible employees and eligible
dependents.
6. To pay Anthem by the premium due date, the premiums on behalf of each member covered under the contract, unless otherwise stated in any
financial agreement between the parties, to submit applications of employees prior to their date of eligibility, to keep all necessary records
regarding membership, to assume responsibility for handling the COBRA and state-mandated continued group coverage and/or conversion
process, if applicable.
1 Anthem is required by the Internal Revenue Service and Centers for Medicare & Medicaid (CMS) regulations to collect this information.
Employer tax ID no. (required): ________ _________ ________
`
__
SG_OHIX_CA_ER 0121
CA_SG_ERAPP-A 01-21
Page 6 of 8
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): ________ _________ ________
`
__
SG_OHIX_CA_ER 0121
CA_SG_ERAPP-A 01-21
Page 7 of 8
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
Company officer signature
X
Printed name
Title
Date (MM/DD/YYYY)
/ /
Employer tax ID no. (required): ________ _________ ________
`
__
SG_OHIX_CA_ER 0121
CA_SG_ERAPP-A 01-21
Page 8 of 8
Section K: Agent/Producer/Broker Attestation — To be completed by the agent/broker
1. To the best of my knowledge, the information on this application is complete and accurate.
2. I am not aware of any information not disclosed by the employer in this application that may have bearing on this risk.
3. I have not completed any of the information contained in the application except with the permission of the applicant and as noted by my initials
and date on the application.
4. I have not signed any of the applications for an employer representative or individual applicant. If after submission of this application, I request
any additions or changes to any of the above information, I will do so only with the written consent of the applicant, and I authorize Anthem Blue
Cross (Anthem) to attribute such additions or changes to me.
5. I have advised the employer, in easy—to—understand language, that a failure to provide complete and accurate information that constitutes fraud
or intentional misrepresentation of material fact may, within 24 months following the issuance of the coverage, result in a loss of coverage
retroactive to the effective date of coverage or re—rating of the employer’s premium retroactive to the coverage effective date and that coverage
shall not be effective until Anthem reviews and approves the application and the employer receives a written notice from Anthem. The employer
understood my explanation.
6. I am the appointed agent/producer/broker and am receiving commissions for the submission of this employer. No portion of my commission
payments from Anthem shall be paid to an agent/broker/producer not appointed/approved by Anthem.
7. I have advised the employer not to terminate any existing coverage until receiving written notification from Anthem that the coverage being
applied for by this application is accepted.
8. I understand that if I have willfully stated as true any material fact I know to be false, I shall, in addition to any applicable penalties or remedies
available under current law, be subject to a civil penalty of up to ten thousand dollars ($10,000).
9. By providing your “wet or electronic” signature below, you acknowledge that such signature is valid and binding.
Electronic Enrollment — Please indicate how employee enrollment will be submitted.
Real-time Online Census Enrollment (OCE) Simple Census 834 Electronic Eligibility Transfer (EET)
Other__________________________________________________________
Writing payable/sub—agent/producer/broker
%
Second writing payable/sub—agent/producer/broker
%
Agency name
Agency ID no.
Agency name
Agency ID no.
Agent/producer/broker name
Agent/producer/broker name
Agent/producer/broker encrypted tax ID no.(SSN)
Agent/producer/broker encrypted tax ID no.(SSN)
Payable/sub-agent/producer/broker encrypted tax ID no.(SSN) if different
Payable/sub-agent/producer/broker encrypted tax ID no.(SSN) if different
Street address
Street address
City
State
Zip code
City
State
Zip code
Phone no.
Fax no.
Phone no.
Fax no.
Email address
Email address
Signature
Date (MM/DD/YYYY)
/ /
Signature
Date (MM/DD/YYYY)
/ /
For General Agent use only
General agent
General agent ID no.
Street address
City
State
ZIP code
Email address
Submit new business applications to: newsguwca@anthem.com
Administration kit will be sent to the Group.
Employers are responsible for sending an electronic or printed copy of the Summary of Benefits and Coverage (also called an “SBC”) to plan
participants and beneficiaries. To access your group’s SBCs, go to www.sbc.anthem.com.
Additional documents can be found on http://www.anthem.com/easyrenew.
Employer tax ID no. (required): ________ _________ ________
`
__
Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association. ANTHEM is a registered
trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.
MCASH4788CML
06/16 CDI3 CDIW1 (12/17) #CA-CDI-001
Get help in your language
Notice of Language Assistance
Curi
ous to know what all this says? We would be too. Here’s the English version:
No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to
you in your language. For help, call us at the number listed on your ID card or 1-888-254-2721. For more help call
the CA Dept. of Insurance at 1-800-927-4357. (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 customer service telephone number on the back of your ID card.
Spani
sh
Servicios lingüísticos sin costo. Puede tener un intérprete. Puede solicitar que le lean los documentos y algunos
puede recibirlos en su idioma. Para obtener ayuda, llámenos al número que figura en su tarjeta de identificación
o al 1-888-254-2721. Para obtener ayuda adicional, llame al Departamento de Seguros de California al 1-800-
927-4357. (TTY/TDD: 711)
Ara
bic
ﻡﺗﻳ ﻡﻳﺩﻘﺗ ﺕﺎﻣﺩﺧ ﺔﻐﻠﻟﺍ ﻥﻭﺩ ﻝﺑﺎﻘﻣ .ﻙﻧﻛﻣﻳ ﺔﻧﺎﻌﺗﺳﻻﺍ ﻡﺟﺭﺗﻣﺑ .ﻙﻧﻛﻣﻳﻭ ﺔﺑﻟﺎﻁﻣﻟﺍ ﻥﺄﺑ ﺃﺭﻘ
ُ
ﺗ ﻙﻟ ﺽﻌﺑ ﺕﺍﺩﻧﺗﺳﻣﻟﺍ ﻥﺃﻭ ﻝﺳﺭُﻳ ﺎﻬﺿﻌﺑ ﻙﺗﻐﻠﺑ .ﻝﻭﺻﺣﻠﻟ ﻰﻠﻋ ،ﺓﺩﻋﺎﺳﻣﻟﺍ
ﻝﺻﺗﺍ ﺎﻧﺑ ﻰﻠﻋ ﻡﻗﺭﻟﺍ ﺩﻭﺟﻭﻣﻟﺍ ﻰﻠﻋ ﺔﻗﺎﻁﺑ ﻑﻳﺭﻌﺗﻟﺍ ﺔﺻﺎﺧﻟﺍ ﻙﺑ ﻭﺃ ﻰﻠﻋ ﻡﻗﺭﻟﺍ 2721-254-888-1.
ﻝﻭﺻﺣﻠﻟ ﻰﻠﻋ ﺩﻳﺯﻣ ﻥﻣ ،ﺓﺩﻋﺎﺳﻣﻟﺍ ﻰﺟﺭُﻳ ﻝﺎﺻﺗﻻﺍ ﺓﺭﺍﺩﺈﺑ ﺎﻳﻧﺭﻭﻔﻳﻟﺎﻛ ﻥﻳﻣﺄﺗﻠﻟ ﻰﻠﻋ ﻡﻗﺭﻟﺍ 4357-927-800-1) .TTY/TDD: 711 (
Arm
enian
Թարգմանչական անվճար ծառայություններ: Մենք կարող ենք Ձեզ թարգմանչի ծառայություններ առաջարկել
Կարող ենք տրամադրել ինչ-որ մեկին, ով փաստաթղթերը կկարդա Ձեզ համար և կուղարկի դրանք Ձեր
լեզվով: Օգնություն ստանալու համար զանգահարեք մեզ Ձեզ ID քարտի վրա նշված հեռախոսահամարով կամ
1-888-254-2721 համարով: Լրացուցիչ օգնության համար զանգահարեք Կալիֆոռնիայի ապահովագրության
նախարարություն հետևյալ հեռախոսահամարով՝ 1-800-927-4357:
(TTY/TDD: 711)
Chinese
免費語言服務。您能獲得免費的譯員。您能聽到以您的語言讀出的文件內容，也能獲得以您的語言而寫的部分文件
。如需協助，請撥打您的 ID 卡上的號碼或者1-888-254-2721聯絡我們。如需更多協助，請撥打1-800-927-4357 聯絡
CA Dept. of Insurance。(TTY/TDD: 711)
Fars
i
ﺕﺎﻣﺪﺧ ﻥﺎﮕﻳﺍﺭ ﯽﻧﺎﺑﺯ .ﯽﻣ ﺪﻴﻧﺍﻮﺗ ﮏﻳ ﻢﺟﺮﺘﻣ ﯽﻫﺎﻔﺷ ﺪﻳﺮﻴﮕﺑ .ﯽﻣ ﺪﻴﻧﺍﻮﺗ ﺪﻴﻫﺍﻮﺨﺑ ﺩﺎﻨﺳﺍ ﺍﺭ یﺍﺮﺑ
ﺎﻤﺷ ﺪﻨﻧﺍﻮﺨﺑ ﻭ ﯽﺧﺮﺑ ﺩﺎﻨﺳﺍ ﺰﻴﻧ ﻪﺑ ﻥﺎﺑﺯ ﻥﺎﺗﺩﻮﺧ ﻥﺎﺘﻳﺍﺮﺑ ﻝﺎﺳﺭﺍ ﺩﻮﺷ .یﺍﺮﺑ ﺖﻓﺎﻳﺭﺩ ،ﮏﻤﮐ ﺯﺍ
ﻖﻳﺮﻃ ﻩﺭﺎﻤﺷ ﺖﺳﺮﻬﻓ ﻩﺪﺷ ﺭﺩ ﺕﺭﺎﮐ ﯽﻳﺎﺳﺎﻨﺷ ﻥﺎﺗ ﻭ ﺎﻳ ﺯﺍ ﻖﻳﺮﻃ 2721-254-888-1
ﺎﺑ ﺎﻣ ﺱﺎﻤﺗ ﺪﻳﺮﻴﮕﺑ .یﺍﺮﺑ ﺖﻓﺎﻳﺭﺩ یﺎﻬﮑﻤﮐ ﺮﺘﺸﻴﺑ ﺎﺑ ﻩﺭﺍﺩﺍ ﻪﻤﻴﺑ ﺎﻴﻧﺮﻔﻴﻟﺎﮐ ﻪﺑ ﻩﺭﺎﻤﺷ
4357-927-800-1 ﺱﺎﻤﺗ ﺪﻳﺮﻴﮕﺑ).TTY/TDD:711 (
Hind
i

    

  
  


  




         ,   ID  
    1-888-254-2721  
     1-800-927-4357  CA     (TTY/TDD: 711)
#CA-CDI-001
Hmong
Tsis Xam Tus Nqi Cov Kev Pab Cuam Ntsig Txog Hom Lus. Koj muaj peev xwm tau txais ib tus neeg txhais lus. Koj muaj
peev xwm tau txais cov ntaub ntawv nyeem ua koj hom lus rau koj mloog thiab yuav xa ib co ntaub ntawv sau ua koj hom lus
tuaj rau koj. Txog rau kev pab, hu rau peb tus nab npawb xov tooj teev tseg cia nyob rau ntawm koj daim ID los sis 1-888-
254-2721. Txog rau kev pab ntxiv, hu xov tooj rau Pab Kas Phais Lub Chaw Ua Hauj Lwm CA tus xov tooj 1-800-927-
4357. (TTY/TDD: 711)
Japanes
e
無料言語サービス。通訳サービスを受けられます。希望する言語で文書を読み上げたり、文書を送るサービスも可能です。支援を
受けるには、IDカードに記載された番号、または 1-888-254-2721 にお電話ください。支援の詳細は、カリフォルニア州保険局（1-
800-927-4357）にお電話ください。(TTY/TDD: 711)
Khm
er

 


  











 







ID  
 1
-
888-254-2721   CA Dept. of Insurance  1-800-927-4357(TTY/TDD: 711)
Kor
ean
무료 언어 서비스. 번역사를 이용하실 수 있습니다. 귀하의 언어로 녹음되어 작성된 문서를 받아보실 수 있습니다.
도움을 받으시려면 ID 카드에 기재된 번호 또는 1-888-254-2721로 전화하십시오. 다른 도움이 필요하시면 1-800-
927-4357로 보험 CA 부서에 문의 주십시오. (TTY/TDD: 711)
Punj
abi

       󰒤   󰐇
  
      󰐈         
       ,     󰓁    1-888-254-2721      , 
󰒦  󰒦  1-800-927-4357   (TTY/TDD: 711)
Rus
sian
Бесплатные языковые услуги. Вы можете получить услуги устного переводчика. Вам могут прочитать
документы или направить некоторые из них на вашем языке. Для получения помощи звоните нам по
телефону, указанному на вашей идентификационной карте, или по номеру 1-888-254-2721. Для получения
дополнительной помощи звоните в Департамент страхования штата Калифорния по номеру 1-800-927-
4357. (TTY/TDD: 711)
Tagalog
Mga Libreng Serbisyo para sa Wika. Maaari kayong kumuha ng interpreter. Maaari ninyong ipabasa ang mga
dokumento at ipadala ang ilan sa mga ito sa inyo sa wikang ginagamit ninyo. Para sa tulong, tawagan kami sa
numerong nakalista sa inyong ID card o sa 1-888-254-2721. Para sa higit pang tulong, tawagan ang CA Dept. of
Insurance sa 1-800-927-4357. (TTY/TDD: 711)
Thai
 

   


 
  1-888-254-2721

  CA Dept. of Insurance  1-800-927-4357
(TTY/TDD: 711)
Vietnamese
Các Dịch Vụ Ngôn Ngữ Miễn Phí. Quý vị có thể có thông dịch viên. Quý vị có thể yêu cầu đọc tài liệu cho quý vị
nghe và yêu cầu gửi một số tài liệu bằng ngôn ngữ của quý vị cho quý vị. Để được trợ giúp, hãy gọi cho số được
ghi trên thẻ ID của quý vị hoặc số 1-888-254-2721. Để được giúp đỡ thêm, hãy gọi cho Sở Bảo Hiểm California
(California Department of Insurance) theo số 1-800-927-4357. (TTY/TDD: 711)
#CA-CDI-001
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 is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ANTHEM is a
registered trademark of Anthem Insurance Companies, Inc.
107750CAMENABC 05/18 DMHC3 DMHCW #CA-DMHC-001#
Get help in your language
Language Assistance Services
Curious to know what all this says? We would be too. Here’s the English version:
IMPORTANT: Can you read this letter? If not, we can have somebody help you read it. You may also be able to
get this letter written in your language. For free help, please call right away at 1-888-254-2721. (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 customer service telephone number on the back of your ID card.
Spanish
IMPORTANTE: ¿Puede leer esta carta? De lo contrario, podemos hacer que alguien lo ayude a leerla. También
puede recibir esta carta escrita en su idioma. Para obtener ayuda gratuita, llame de inmediato al 1-888-254-2721.
(TTY/TDD: 711)
Arabic




.711 :TTD/TTY
Armenian
ՈՒՇԱԴՐՈՒԹՅՈՒՆ. Կարողանո՞ւմ եք ընթերցել այս նամակը: Եթե ոչ, մենք կարող ենք տրամադրել ինչ-որ
մեկին, ով կօգնի Ձեզ՝ կարդալ այն: Կարող ենք նաև այս նամակը Ձեզ գրավոր տարբերակով տրամադրել:
Անվճար օգնություն ստանալու համար կարող եք անհապաղ զանգահարել 1-888-254-2721
հեռախոսահամարով: (TTY/TDD: 711)
Chinese
重要事項：您能看懂這封信函嗎？如果您看不懂，我們能夠找人協助您。您有可能可以獲得以您的語言而寫的本信
函。如需免費協助，請立即撥打1-888-254-2721。(TTY/TDD: 711)
Farsi


711 :TTD/TTY
Hindi

? ,  

 ,

1-888-254-2721 
 (TTY/TDD: 711)
Hmong
TSEEM CEEB: Koj puas muaj peev xwm nyeem tau daim ntawv no? Yog hais tias koj nyeem tsis tau, peb muaj peev xwm cia
lwm tus pab nyeem rau koj mloog. Tsis tas li ntawd tej zaum koj kuj tseem yuav tau txais daim ntawv no sau ua koj hom lus
thiab. Txog rau kev pab dawb, thov hu tam sim no rau tus xov tooj 1-888-254-2721. (TTY/TDD: 711)
Japanese
重要：この書簡を読めますか？もし読めない場合には、内容を理解するための支援を受けることができます。また、この書簡を希望
する言語で書いたものを入手することもできます。次の番号にいますぐ電話して、無料支援を受けてください。 1-888-254-2721
(TTY/TDD: 711)
#CA-DMHC-001#
Khmer
?  

 1-888-254-2721 (TTY/TDD: 711)
Korean
중요: 이 서신을 읽으실 수 있으십니까? 읽으실 수 없을 경우 도움을 드릴 사람이 있습니다. 귀하가 사용하는
언어로 쓰여진 서신을 받으실 수도 있습니다. 무료 도움을 받으시려면 즉시 1-888-254-2721로 전화하십시오.
(TTY/TDD: 711)
Punjabi
󰒤󰐈? 󰒤, 󰒤󰐈󰒤
󰐇, 
(TTY/TDD: 711)
Russian
ВАЖНО. Можете ли вы прочитать данное письмо? Если нет, наш специалист поможет вам в этом. Вы
также можете получить данное письмо на вашем языке. Для получения бесплатной помощи звоните по
номеру 1-888-254-2721. (TTY/TDD: 711)
Tagalog
MAHALAGA: Nababasa ba ninyo ang liham na ito? Kung hindi, may taong maaaring tumulong sa inyo sa
pagbasa nito. Maaari ninyo ring makuha ang liham na ito nang nakasulat sa ginagamit ninyong wika. Para sa
libreng tulong, mangyaring tumawag kaagad sa 1-888-254-2721. (TTY/TDD: 711)
Thai


    
 
 

1-888-254-2721 (TTY/TDD: 711)
Vietnamese
QUAN TRỌNG: Quý vị có thể đọc thư này hay không? Nếu không, chúng tôi có thể bố trí người giúp quý vị đọc
thư này. Quý vị cũng có thể nhận thư này bằng ngôn ngữ của quý vị. Để được giúp đỡ miễn phí, vui lòng gọi
ngay số 1-888-254-2721. (TTY/TDD: 711)
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.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

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

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 1 June 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document