Employee Change Form

Employee Change Form
INSTRUCTIONS:
Please complete this form ONLY if you are making changes to your existing coverage. If you are APPLYING for coverage or ADDING a dependent(s),
complete the Anthem Blue Cross and Blue Shield (Anthem) Enrollment Application instead of this form.
If you are canceling coverage for a dependent or changing a name, please provide a reason in the designated sections. Complete electronically, or in blue
or black ink and return to your employer. Please use extra sheets of paper, if necessary. NOTE: Some changes may be made by accessing anthem.com.
SECTION 1: EMPLOYER/GROUP USE — Required.
Employer name
Group no.
Employer address
Sub-group no./Life division no. Requested effective date
Life classification
Employee no./Dept. name
SECTION 2: REASON FOR CHANGE — Required. Please be sure to provide date of event.
Event date (MM/DD/YYYY)
Address
Add dependent
Change Life beneficiary
Name change
Cancel dependent
Change Life classification
Benefit change
Conversion
Other: _____________________
Enrollment in Medicare (Fill in section 7)
Waiving coverage (Fill in section 10)
SECTION 3: PLAN/TYPE OF COVERAGE
Medical
If multiple Medical Plans are available, please indicate the plan type below and write plan number in the space provided.
HMO
POS
PPO
Anthem EssentialSM PPO
Lumenos® HSA PPO*
Lumenos® HRA PPO
Lumenos® HIA PPO
Type of coverage
Lumenos® Health Incentive Account Plus PPO
Lumenos® Deductible First HRA PPO
Employee only
Employee+spouse (DP)
Employee+child(ren)
Family coverage
No coverage
If multiple Medical Plans are available, write plan number: ____________________________________________________
*Anthem will facilitate the opening of a Health Savings Account (HSA) in your name, if directed by your Employer.
Dental
Vision
Type of coverage
Type of coverage
Dental Blue®100/200/300
Dental Blue® 100
Employee only
Employee+child(ren)
No coverage
SECTION 4: EMPLOYEE INFORMATION — Required.
Last name
First name
M
F
Sex
Employee only
Employee+child(ren)
No coverage
Employee+spouse
Family coverage
M.I.
Single Married Height Weight Home phone no.
Divorced
Life
Life
Employee+spouse (DP) (Fill in section 6)
Family coverage
Date of birth (MM/DD/YYYY)
Age
Email address
Address
City
Social Security no.* (Required)
Hours worked per week
State ZIP code
County
SECTION 5: FAMILY INFORMATION — Spouse and dependents to be changed/canceled, attach a separate sheet, if necessary.
Spouse/Domestic Partner
Please read the Genetic Information Non-discrimination Act (GINA) information in section 8, Significant Terms, prior to answering the questions in section 5.
Add Change Cancel
Reason for change
Last name
First name
Date of birth (MM/DD/YYYY)
Sex
M F
Relationship to employee
Spouse Domestic Partner
M.I.
Social Security no.* (Required)
If spouse/DP address is different than employee, provide full address
*Anthem is required by the Internal Revenue Service to collect this information.
AMO-83 Rev. 5/15
Life and Disability products underwritten by Anthem Life Insurance Company. In Missouri, (excluding 30 counties in the Kansas City area) Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE®
Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten
by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross and Blue Shield Association.
ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
27922MOMENABS Rev. 5/15
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Employee name: _____________________________________________ Social Security no.* (Required): __________________________
SECTION 5: FAMILY INFORMATION (Continued) — Spouse and dependents to be changed/canceled, attach a separate sheet, if necessary.
Please read the Genetic Information Non-discrimination Act (GINA) information in section 8, Significant Terms, prior to answering the questions in section 5.
Dependent
Add Cancel
Reason for change
Last name
First name
Date of birth (MM/DD/YYYY)
Add Dependent
Change Change Sex
M Cancel
Social Security no.* (Required)
Relationship to employee Child If dependent address is different than employee, provide full address
Other: _______________
F
Reason for change
Last name
Date of birth (MM/DD/YYYY)
M.I.
First name
Sex
M M.I.
Social Security no.* (Required)
Relationship to employee Child If dependent address is different than employee, provide full address
Other: _______________
F
SECTION 6: LIFE AND DISABILITY INSURANCE
Week Month Year
Current income $: _____________ Hour Basic Life
Supplemental Life: ________ x annual earnings
Dependent Life
OR $: _____________________
Currently actively at work Basic AD&D
Optional AD&D
Yes No If “No,” reason: ___________
Short-Term Disability: _______________
Long-Term Disability: _______________
Anthem ByDesign Buy-Up. Check appropriate box and write in the percentage next to the benefit selected. Complete separate election form.
Short-Term Disability____________% Long-Term Disability_____________% Basic Life
Primary beneficiary
Last name
First name
M.I.
Social Security no.
Relationship to employee
Age
Contingent beneficiary
Last name
First name
M.I.
Social Security no.
Relationship to employee
Age
SECTION 7: OTHER HEALTH COVERAGE
Do you and/or your dependents have other health coverage? Yes No If “Yes,” complete below.
On the day your coverage begins, list family members, including yourself, who will be covered by any other health coverage
Provide name, phone no. and address of the HMO or insurance company
Policy/Certificate holder name
Policy/Certificate no.
Social Security no.
Date of birth (MM/DD/YYYY)
Effective date (MM/DD/YYYY)
Relationship to employee
Yes No If “Yes,” complete below.
Are you and/or your dependents enrolled in Medicare or Medicaid? Enrollee name
Medicare/Medicaid ID no.
Medicare Part A effective date Medicare Part B effective date ESRD onset date
Enrollee name
Medicare/Medicaid ID no.
Medicare Part D ID no.
Reason for Medicare entitlement: Medicare Part A effective date Medicare Part B effective date ESRD onset date
Medicare Part D Carrier
Age Disability ESRD and Disability Medicare Part D effective date Medicare Part D term date
End-stage renal disease (ESRD)
SECTION 8: SIGNIFICANT TERMS, CONDITIONS AND AUTHORIZATIONS (TERMS) — Please read this section carefully before signing the application.
Genetic Information Non-discrimination Act (GINA): When answering questions about a person on this form, only give answers about that person, and do not include
any genetic information. Genetic information includes family health history, genetic testing, genetic services, genetic counseling, or genetic diseases for which the person
may be at risk. All responses about a person will only be considered and used for that person.
Health Savings Account Notice: I authorize the financial custodian of my Health Savings Account (HSA) to give Anthem Blue Cross and Blue Shield facts about my HSA,
including account number, account balance and account activity. I understand that I may take back my authorization by written request to Anthem Blue Cross and Blue Shield
at any time.
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.
*Anthem is required by the Internal Revenue Service to collect this information.
AMO-83 Rev. 5/15
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Employee name: _____________________________________________ Social Security no.* (Required): __________________________
SECTION 8: SIGNIFICANT TERMS, CONDITIONS AND AUTHORIZATIONS (TERMS) (Continued) — Please read this section carefully before signing the application.
1. I understand that I may not assign any payment under my Anthem Blue Cross
and Blue Shield program.
2. I agree to have money taken from my wages/pension, if necessary, to cover
the premium cost for the coverage applied for.
3. I am asking for the coverage I chose on this form. If I made choices that are
not available to me, I agree that my choices may be changed to those on the
employer’s application.
4. I understand that, to the extent allowed by law, Anthem reserves the right
to accept or decline to this application for coverage (and that Anthem Life
Insurance Company may accept only certain people or terms for coverage),
and that no right is created by my application for coverage.
5. I agree that I will let my employer know right away of any changes
that would make me or any dependent(s) ineligible for this coverage.
6. By signing this application, I agree to the taping or monitoring of any phone
calls between Anthem and myself.
I have read and accept the Significant Terms, Conditions and Authorizations as a condition of coverage. My answers to all questions are true to the best of my knowledge,
and I understand that Anthem relies on these answers in accepting this application. I understand that any untrue answers or failure to report new medical information
before my effective date may cause a material change in coverage or premium rates. For a period of two (2) years from the earlier of the policy date or the issue date,
Anthem may deny benefits, rescind your policy or cancel coverage based on material misrepresentation of significant omission found in this application. I agree to these
terms for myself and on behalf of any dependents covered by the Plan. I am acting as their agent and representative.
SECTION 9: SIGNATURE — Required, if you are applying for coverage. Please review your application for errors or omissions.
Read section 8 carefully before signing.
I have read and understand the language in the TERMS section of this application and agree to all of its terms.
Employee signature
Date (MM/DD/YYYY)
X
SECTION 10: WAIVER OF COVERAGE — Complete for yourself and/or any eligible dependents. Check all that apply.
Type of coverage
Medical
Dental
Vision
Life
All
Waived for
Name
Self
Spouse/DP
Child(ren)
Self
Spouse/DP
Child(ren)
Self
Spouse/DP
Child(ren)
Self
Spouse/DP
Child(ren)
Self
Spouse/DP
Child(ren)
Reason for waiving (already protected by coverage)
Anthem
Other carrier
No coverage
Anthem
Other carrier
No coverage
Anthem
Other carrier
No coverage
Anthem
Other carrier
No coverage
Anthem
Other carrier
No coverage
Certificate/Policy no. or Carrier name and ID no.
Certificate/Policy no. or Carrier name and ID no.
Certificate/Policy no. or Carrier name and ID no.
Certificate/Policy no. or Carrier name and ID no.
Certificate/Policy no. or Carrier name and ID no.
Check all that apply:
I have been given a chance to apply for Anthem Blue Cross and Blue Shield coverage, and after careful thought, I have decided not to take this offer. If I want to
apply for coverage at a later date, I can, based on established methods. If I have decided not to take this offer of coverage for myself or my dependents (including
my spouse) because of other health insurance coverage, I may be able to enroll myself or my dependents later, as long as I ask to sign up within 31 days after other
coverage ends. Also, if I have a dependent as a result of marriage, birth, adoption or placement for adoption, I may be able to enroll myself and my dependents if I
request enrollment within 31 days after the marriage, birth, adoption or placement of adoption.
I also understand that my dependents and I may sign up under two more circumstances:
}}Either my or my dependents’ Medicaid or Children’s Health Insurance Program (CHIP) coverage is terminated as a result of loss of eligibility.
}}My dependents or I become eligible for a subsidy (state premium aid program).
In these cases, I may be able to enroll myself and my dependents if I request enrollment within 60 days of the loss of Medicaid/CHIP or of the eligibility determination.
I have been given a chance to apply for the group life benefits offered by my employer/group. The benefits have been explained to me. I and/or my dependent(s)
have decided not to join. My dependent(s) or I were not pressured by my employer/group, agent or life carrier, to say no to this coverage, but instead we chose
to say no of our own accord. I agree that if I want to ask for coverage in the future, I may be asked to give proof of insurability at my own cost.
I am covered, or will be covered, under some other plan that is not sponsored by my employer. I am not covered under Health Insurance Risk Sharing Program (HIRSP).
My dependents are covered, or will be covered, under some other plan that is not sponsored by my employer. My dependents are not signed up for coverage under
Health Insurance Risk Sharing Program (HIRSP).
Other: ____________________________________________________________________________________________________________________
SIGNATURE — Required, if you want to waive coverage for yourself and your dependents.
Employee signature
Date (MM/DD/YYYY)
X
*Anthem is required by the Internal Revenue Service to collect this information.
AMO-83 Rev. 5/15
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