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  • Employee Application - Anthem

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Attach a separate sheet of paper and sign and date. Please use 4 digits for years (e.g. 2013, not 13). EMPLOYER USE ONLY Group no. Division no. SECTION 1: REASON FOR APPLICATION Event date (MM/DD/YYYY) Class New enrollment Change of class Family addition Late enrollment Reinstatement Change of name/address Waive coverages (complete Sections 1, 2, 6 and 10) COBRA effective date: SECTION 2: APPLICANT INFORMATION Last name Social Security no. Single Marital status Street address Yes.

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Written reconsiderations To submit a written reconsideration, use a blank Claim Information/Adjustment Request 151 Form, available online at https://mediproviders.anthem.com/va > Claims > Forms. Once the form is complete, attach any necessary information and mail it to: HealthKeepers, Inc.

Visit .hellofurther.com or call us toll free at 800-859-2144 to check your account balance. The items being purchased are not eligible expenses. For a list of eligible expenses, visit .hellofurther.com.

Your employer's HSA contributions are reported on your W2 and included as part of the total account contributions listed on form 5498-SA.

Anthem Life's product offerings for employee benefit plans include group term life, accidental death and dismemberment (AD&D), dependent life, supplemental life, and AD&D. The employer selects the coverage and benefit amounts and pays all or part of the premium. Products and availability vary by state.

Will my HSA account remain open if I have a $0 balance? The account will remain open if you have a $0 balance. There is no fee assessed to you for having a $0 balance.

You can check your HSA balance by visiting the Member Website, where you will have secure, 24/7 access to your account balances and transaction history. Learn more about managing your account.

Michelle's employer, the insurance company Anthem, had adopted a suite of technology designed to track workers' productivity. She remembers the software being presented as a measure to keep track of workers during the pandemic but now, more than a year later, Anthem still uses it.

Log in to anthem.com and select “Access your BenefitWallet HSA”. Check your claims and track your account balance.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232