Loading
Form preview picture

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. .

How It Works

deletions rating
4Satisfied
58 votes

Tips on how to fill out, edit and sign Terminations online

How to fill out and sign Cancellations online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Have you been trying to find a quick and practical tool to complete Anthem 10262CAMEN at a reasonable price? Our platform will provide you with a rich variety of forms available for submitting online. It only takes a few minutes.

Follow these simple actions to get Anthem 10262CAMEN completely ready for submitting:

  1. Select the form you need in our library of legal forms.
  2. Open the document in the online editing tool.
  3. Go through the guidelines to find out which details you will need to include.
  4. Select the fillable fields and include the required data.
  5. Put the date and place your electronic signature as soon as you fill out all of the fields.
  6. Check the document for misprints as well as other errors. If there?s a need to correct some information, the online editing tool along with its wide variety of tools are ready for your use.
  7. Save the new document to your device by clicking Done.
  8. Send the e-document to the intended recipient.

Filling in Anthem 10262CAMEN does not have to be stressful any longer. From now on easily get through it from your home or at your workplace from your mobile device or desktop.

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to Anthem 10262CAMEN

  • California
  • SSN
  • deletions
  • Oxnard
  • HMO
  • 10262CAMEN
  • epo
  • licensee
  • Terminations
  • NOTIFICATIONS
  • electing
  • cancellations
  • dependents
  • ELIGIBILITY
  • RETROACTIVE
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.