Get Wi Anthem Employee Enrollment Application For 1-50 Employee Small Groups 2017-2025

Completing the WI Anthem Employee Enrollment Application is an essential step for individuals looking to enroll in health coverage for small groups in Wisconsin. This guide aims to provide clear and supportive instructions to help users fill out the application accurately and efficiently.

Follow the steps to complete your employee enrollment application.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by filling out Section A, which requires your personal information. Provide your last name, first name, middle initial, and Social Security number. Ensure your home address, phone numbers, and email address are filled accurately, as this information is crucial for communication and eligibility.
3. In Section A, also indicate your marital status and employment status. Make sure to enter your date of hire and the number of hours you work per week.
4. Proceed to Section B to select the type of application you are submitting. Choose if it is new enrollment, open enrollment, or due to a qualifying event. Clearly mark the qualifying event and the date it occurred, if applicable.
5. Move on to Section C to choose your coverage types. Indicate your selections for medical, dental, vision, and life/disability coverage. Ensure you fill out the specific contract codes as advised by your employer for each type of selected coverage.
6. Complete Section D, where you will provide information about any dependents you wish to include in the coverage. Ensure that each dependent's information, including their social security numbers and relationship to you, is accurately documented.
7. In Section E, state whether you or any applicants are eligible for Medicare or other group coverage. Fill out necessary details if applicable.
8. If you are choosing to waive coverage, complete Section F by indicating who will be declining coverage. Provide reasons for the waivers as required.
9. Review Section G to read and understand the terms, conditions, and authorizations. By signing this section, you affirm the accuracy of provided information and authorize deductions from your salary, if necessary.
10. Once you have filled out all sections, review the entire application for any errors. When satisfied, save your changes, download, print, or share the form as required.

Start filling out your enrollment application online today!