Follow the steps to successfully complete your application online.

1. Click ‘Get Form’ button to retrieve the application form and open it for editing.
2. Begin by identifying the effective date of coverage. Clearly state the date when the coverage is expected to start.
3. In the benefits section, select the health plan options that best suit your needs from the list provided, such as Blue Access® (PPO) or Anthem EssentialSM Choice PPO. Make sure to choose the plans available in your state.
4. Complete the employer information section accurately, including the legal name of your organization, home office address, and contact details like email and phone number.
5. Indicate the type of business entity and provide your Tax ID/FEIN as this is required for processing your application.
6. Fill out details regarding employee eligibility, including the total number of employees and those who are not Actively At Work. Include waiting period details and ensure you specify if any classes of employees have different waiting periods.
7. If applicable, answer the questions pertaining to COBRA administration and Medicare Secondary Payer status. This ensures compliance with regulations.
8. Acknowledge the contribution and minimum participation requirements for health coverage. Note if your group has different contribution levels for various benefits.
9. Review the signature section carefully. Ensure that the authorized representative signs and dates the application, confirming that all information provided is accurate.
10. Once all sections are completed, save your changes. You can then download, print, or share the form as needed.

Get started on your application now to ensure you have the coverage you need.