Anthem Enrollment Application
Employee Enrollment Application For 51+ Employee Groups Georgia
You, the employee, must complete this application. You are solely responsible for its accuracy and completeness. To avoid the possibility of delay, answer all questions and be sure to sign and date your application.
Please complete electronically or in blue or black ink only. Employer name S t e r l ing Estates
Group no.
Subsection
L 0 7 5 5 8
Section A: Employee information Last name
First name
M.I.
Social Security no.* (required)
Birthdate (MMDDYYYY)
Home address
City
County
State ZIP code
Marital status Single
Primary phone no.
Sex
Male
Female
Married
Domestic Partner
Employee email address
Hire date (MMDDYYYY)
No. of hours worked per week
Employment status Full time
Part time
Disabled
Retired
Primary Care Physician (PCP) name
PCP ID no.
Existing patient? Yes No
Section B: Application type Select one
New enrollment Open enrollment
COBRA — (not applicable to life and disability) Select qualifying event
Qualifying event date
Left employment
Reduction in hours
Death
Loss of dependent child status
Divorce or legal separation
Medicare (not applicable to life and disability) Covered employee’s Medicare entitlement (not applicable to life and disability)
Additional qualifying events for Life and Disability: Marriage/Domestic Partnership/Civil Union Birth, adoption of child, legal guardianship of child
Divorce/terminate Domestic Partnership/Civil Union
Death of spouse
Death of child
Spouse left employment and lost group life insurance — applicable only for Life Change in class from full–time to part–time/part–time to full–time Qualifying event date: (MMDDYY) * Anthem Blue Cross and Blue Shield (Anthem) is required by the Internal Revenue Service to collect this information.
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10 STERLING ESTATES 2023 BENEFITS GUIDE
Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Life and Disability products are underwritten by Greater Georgia Life Insurance Company using the trade name Anthem Life. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
F0301.EE – 01012023
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