Get CA Anthem GC4050 2017-2024

Anthem Blue Cross Enrollment Form Please return the completed enrollment form to your employer. Employer Notice After your review of the enrollment form for completeness please fax or mail the form to PO Box 629 Woodland Hills CA 91365-0629 Fax no. 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. EFFECTIVE DATE The effective date of coverage is subject to Anthem Blue Cross approval. COBRA/CAL-COBRA CONTINUATION COVERAGE You may continue your health care coverage by 1 completing the remainder of this form 2 signing your name in the blank space below 3 paying your Total Monthly Continuation Payment and 4 mailing this form to Anthem Blue Cross no later than sixty 60 days after the date you receive this notice. EFFECTIVE DATE The effective date of coverage is subject to Anthem Blue Cross approval. COBRA/CAL-COBRA CONTINUATION COVERAGE You may continue your health care coverage by 1 completing the remainder of this form 2 signing your name in the blank space below 3 paying your Total Monthly Continuation Payment and 4 mailing this form to Anthem Blue Cross no later than sixty 60 days after the date you receive this notice. If you fail to choose COBRA Continuation Coverage within sixty 60 days after the date you receive this notice your qualification for coverage will end. W 9 Certification Language As part of the W 9 Certification required by the Internal Revenue Service IRS I certify that the Social Security number shown on this form is my correct taxpayer identification number or I am waiting for a number to be issued to me and I am not subject to backup withholding because a I am exempt from backup withholding or b I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest or dividends or c the IRS has notified me that I am no longer subject to backup withholding and I am a U.S. citizen or other U.S. person. REQUIREMENT FOR BINDING ARBITRATION IF YOU ARE APPLYING FOR COVERAGE PLEASE NOTE THAT ANTHEM BLUE CROSS AND ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY REQUIRE BINDING ARBITRATION TO SETTLE ALL DISPUTES 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 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. It is understood that any dispute including disputes relating to the delivery of services under the plan/policy or any other issues related to the plan/policy including 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 as 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. THIS MEANS THAT YOU AND ANTHEM BLUE CROSS AND/OR ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY ARE WAIVING THE RIGHT TO A JURY TRIAL AND PARTICIPATION IN A CLASS ACTION FOR BOTH MEDICAL MALPRACTICE CLAIMS AND ANY OTHER DISPUTES INCLUDING DISPUTES RELATING TO THE DELIVERY OF SERVICE UNDER THE PLAN/POLICY OR ANY OTHER ISSUES RELATED TO THE PLAN/POLICY. Note If you do not elect available COBRA Continuation of Medical Coverage you will lose certain rights under federal law HIPAA to guaranteed issue individual coverage. W 9 Certification Language As part of the W 9 Certification required by the Internal Revenue Service IRS I certify that the Social Security number shown on this form is my correct taxpayer identification number or I am waiting for a number to be issued to me and I am not subject to backup withholding because a I am exempt from backup withholding or b I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest or dividends or c the IRS has notified me that I am no longer subject to backup withholding and I am a U.S. citizen or other U.S. person. REQUIREMENT FOR BINDING ARBITRATION IF YOU ARE APPLYING FOR COVERAGE PLEASE NOTE THAT ANTHEM BLUE CROSS AND ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY REQUIRE BINDING ARBITRATION TO SETTLE ALL DISPUTES 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 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. It is understood that any dispute including disputes relating to the delivery of services under the plan/policy or any other issues related to the plan/policy including 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 as 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. If you do not pay your initial monthly premium within 45 days after your election of COBRA Continuation Coverage or if payment of succeeding premiums are not received within the 30-day grace period thereafter your coverage will end. Note If you do not elect available COBRA Continuation of Medical Coverage you will lose certain rights under federal law HIPAA to guaranteed issue individual coverage. W 9 Certification Language As part of the W 9 Certification required by the Internal Revenue Service IRS I certify that the Social Security number shown on this form is my correct taxpayer identification number or I am waiting for a number to be issued to me and I am not subject to backup withholding because a I am exempt from backup withholding or b I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest or dividends or c the IRS has notified me that I am no longer subject to backup withholding and I am a U.S. citizen or other U.S. person. REQUIREMENT FOR BINDING ARBITRATION IF YOU ARE APPLYING FOR COVERAGE PLEASE NOTE THAT ANTHEM BLUE CROSS AND ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY REQUIRE BINDING ARBITRATION TO SETTLE ALL DISPUTES 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 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. Automatic FSA processing is not possible for HMO enrollees and those with I authorize payroll deductions on the following coverage through another health plan. Reminder Automatic FSA processing is the equivalent of signing and Health Care Account submitting an FSA claim form which states that you are eligible for FSA reimbursement and that you will not claim Dependent Care FSA reimbursed expenses on your income tax return. Blue View Vision offered by Anthem Blue Cross Life and Health Insurance Company VISION Annual salary LIFE INSURANCE All the coverages listed may not be offered under your plan. To elect dependent coverage the corresponding employee coverage must be selected. List all life insurance beneficiaries in the Life Insurance Beneficiary Designation Information section. Elected Benefit Benefit Amount Basic Life AD D Optional Life Employee Optional AD D Employee Dependent Life Spouse Optional Dependent Life/Spouse Optional AD D Spouse Optional AD D Child Short Term Disability Voluntary Short Term Disability Long Term Disability Voluntary Long Term Disability LANGUAGE CHOICE optional English Spanish Chinese Korean Other please specify SECTION 2 APPLICANT S PERSONAL INFORMATION Social Security numbers are required under CMS Regulations and by the IRS Last name First name M. I. Marital status Single Married Domestic Partner DP Street address Apt. no. of dependents including spouse Spouse/DP Social Security or ID no. required City Hire date/Rehire date Employer name State Job title Class ZIP code Dept. no. Home phone no. S.A. POS Blue Cross Plus BC Exclusive non-California resident H. I. A. H. I. A. Plus Priority Select HMO ACO Flex Other Medicare non-California resident Indicate Medical Group/IPA No. in the Employee and Family Information section. DENTAL Dental Net HMO Dental Blue PPO PPO Dental Prime select one of the following National Dental Blue PPO Choice Dental PPO Dental Plan A Plan B Plan C Plan D National PPO Dental Voluntary PPO Dental Complete select one of the following National Voluntary PPO Dental PPO Dental Dental Blue Complete Incentive UniAccount Flexible Spending account Indicate payroll deductions from their Health Care FSA account. Automatic FSA processing is not possible for HMO enrollees and those with I authorize payroll deductions on the following coverage through another health plan. Reminder Automatic FSA processing is the equivalent of signing and Health Care Account submitting an FSA claim form which states that you are eligible for FSA reimbursement and that you will not claim Dependent Care FSA reimbursed expenses on your income tax return. Blue View Vision offered by Anthem Blue Cross Life and Health Insurance Company VISION Annual salary LIFE INSURANCE All the coverages listed may not be offered under your plan. To elect dependent coverage the corresponding employee coverage must be selected. List all life insurance beneficiaries in the Life Insurance Beneficiary Designation Information section. Elected Benefit Benefit Amount Basic Life AD D Optional Life Employee Optional AD D Employee Dependent Life Spouse Optional Dependent Life/Spouse Optional AD D Spouse Optional AD D Child Short Term Disability Voluntary Short Term Disability Long Term Disability Voluntary Long Term Disability LANGUAGE CHOICE optional English Spanish Chinese Korean Other please specify SECTION 2 APPLICANT S PERSONAL INFORMATION Social Security numbers are required under CMS Regulations and by the IRS Last name First name M.