Small Group Eligibility Statement
anthem.com/ca
12252CAEENABC Rev. 1/19
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.
3345900 12252CAEENABC Eligibility Statement Prt FR 01 19
Company Owner/Officer (please print)
Company name Percentage of ownership in firm*
Please indicate your organization type:
Sole Proprietor Corporation Limited Liability Company Partnership Limited Partnership Limited Liability Partnership
Other: _________________________________________________
If you are a shareholder, member, officer or have an ownership stake in a corporation or Limited Liability Company (LLC)/Limited Liability Partnership (LLP) and
are not listed on the Quarterly State Tax Withholding Report, please complete this form to establish your relationship to the company referenced above.
1. I attest that, although my name does not appear on the Quarterly State Tax Withholding Report of the above-named company, the following is true:
a. I am a shareholder, member, officer or have an ownership stake in the above-named corporation or LLC/LLP.
b. I am actively at work at this company working an average of 30 hours per week over the course of a month on a permanent and full-time basis.
c. I draw monetary compensation from this company on a regular basis.
d. I do not derive substantial earned income from any other employer and am not eligible for other employer-sponsored coverage.
2. I will provide additional ownership/business validation documentation, including the appropriate IRS forms, as requested.
3. If my eligibility is required to meet the minimum group size to qualify for Small Group business coverage as it relates to the above-named company,
I attest I am not: (a) an individual that wholly owns the above named company on his/her own or with his/her Spouse/Domestic Partner; (b) the spouse
of a sole proprietor; (c) a partner of a partnership or their spouse; (d) a 2 percent S corporation shareholder; (e) a worker described in Section 3508 of
Title 26, Internal Revenue Code; or (f) a leased employee (as defined in 26 U.S.C. § 414(n)(2).
Additional attestation for owner of multiple entities:
If I am an owner of multiple entities, I have designated this entity as the sole entity for which I am eligible as an owner for Anthem Blue Cross (Anthem) coverage.
I understand this information may be subject to audit and agree to provide Anthem, or its affiliates, with any and all information and documentation necessary to
prove the above statements. I also understand that any misrepresentation by me of my true circumstances may result in termination of group health coverage
from Anthem, or its affiliates, Small Group Health Plan for myself, my enrolled dependents and/or this company as Anthem, or its affiliates, may choose. Anthem,
or its affiliates, also expressly reserve any other rights and remedies.
Signature
X
Date
* If the percentage of ownership is zero, the enrollee must appear on the Quarterly State Tax Withholding Report.
