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Get Anthem 10262CAMEN 2009

A. Employee change of address New street address City State ZIP code New local address B. Group change of address New billing address To expedite processing you may Fax form to 805-499-0842 If faxed please retain original. OR Mail form to Anthem Blue Cross P. 2-50 Small Group Employee Information Change Form Note Credit for deletions will appear on a subsequent billing. Do not send this form with payment. Group name Group no. use this form for Notification of terminations of employees/dependents COBRA/Cal-COBRA notifications COBRA is for groups of 20 or more Cal-COBRA applies to groups with 2 to 19 full-time and part-time employees Address changes Name of person completing form Signature Date / Due date Phone no. 1. terminating employees Please submit deletions as they occur. RETROACTIVE CANCELLATIONS ARE NOT ALLOWED. Note If the employee is Federal COBRA-eligible PLEASE be sure the employee has elected COBRA before checking YES to Start Federal COBRA. Please refer to Federal COBRA Guidelines in regard to Federal COBRA eligibility. SSN or ID no. Employee name Last name first name Termination date Offer Cal-COBRA Cal-COBRA or Federal COBRA Qualifying Event Start Federal COBRA m Yes m No 2. active employees declining coverage for self or dependent s Employees cancelling coverage for themselves or their dependent s MUST COMPLETE Sections 2 and 4 of the Employee Application in compliance with California State Law AB 1672. Please attach the completed application declining coverage to this form* Note Federal COBRA-eligible dependent MUST COMPLETE an application to enroll on Federal COBRA. Check one Coverage to be deleted Is dependent electing m Employee m Dependent m Medical m Dental m Life m Vision Reason for cancellation date 3. employee/group change of address This section should be used for groups and/or member address changes. Note The Group MAY experience a rate change upon the address change of an Employee. Employees moving out of state are not eligible for HMO or EPO plans. O. Box 9062 Oxnard CA 93031-9602 10262CAMEN Rev* 7/09 Anthem Blue Cross is the trade name of Blue Cross of California* Independent licensee of the Blue Cross Association* ANTHEM is a registered trademark of Anthem Insurance Companies Inc* The Blue Cross name and symbol are registered marks of the Blue Cross Association*. 2-50 Small Group Employee Information Change Form Note Credit for deletions will appear on a subsequent billing. Do not send this form with payment. Group name Group no. use this form for Notification of terminations of employees/dependents COBRA/Cal-COBRA notifications COBRA is for groups of 20 or more Cal-COBRA applies to groups with 2 to 19 full-time and part-time employees Address changes Name of person completing form Signature Date / Due date Phone no. Do not send this form with payment. Group name Group no. use this form for Notification of terminations of employees/dependents COBRA/Cal-COBRA notifications COBRA is for groups of 20 or more Cal-COBRA applies to groups with 2 to 19 full-time and part-time employees Address changes Name of person completing form Signature Date / Due date Phone no. 1. terminating employees Please submit deletions as they occur. RETROACTIVE CANCELLATIONS ARE NOT ALLOWED. .

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