Anthem Enrollment Application
Social Security no.* (required)
Section C: Type of coverage 1. Medical coverage
OAP5/72LF
HMO
PPO
POS
EPO
Enter product name: __________________________________________________
Select network:
✔
Add HRA Wrap (Administered by Anthem) Member medical coverage — select one:
Employee only
Employee + Spouse/Domestic Partner
Employee + child(ren)
Family
2. Flexible Spending Account (FSA) coverage — Multiple plans can be selected. Healthcare FSA (excluded if you have an HSA plan) Limited-Purpose FSA (for dental and vision services) Dependent Care FSA
Commuter Parking Commuter Transit No FSA coverage at this time
3. Dental coverage
Enter product selected: ________________________________________________________ Member dental coverage — select one: Employee only Employee + Spouse/Domestic Partner 4. Vision coverage Enter product selected: ________________________________________________________ Member vision coverage — select one: Employee only Employee + Spouse/Domestic Partner
Employee + child(ren)
Family
Employee + child(ren)
Family
5. Life and disability coverage If you select life and/or disability coverage over the guarantee issue amount or are a late entrant an Evidence of Insurability form may be sent to you to complete. These coverages will become effective on the date established by the provisions of the group contract and certificates issued thereunder. Your employer will advise you of your plan options. These coverages may be subject to medical evidence underwriting and would only become effective upon approval.
Basic Life and AD&D Basic Dependent Life Supplemental/Voluntary Life and AD&D ($15,000)
Short Term Disability Long Term Disability
✔
$_____________ (employee amount) Supplemental/Voluntary Dependent Life Spouse $_____________ (spouse amount) Supplemental/Voluntary Dependent Life Child $_____________ (child amount)
Voluntary Short Term Disability Voluntary Long Term Disability Voluntary AD&D
Current annual income $_____________
Life and disability class no.
If choosing medical please select beneficiary for included $15,000 life insurance policy
Beneficiary designation — Attach a separate sheet if necessary. Beneficiary type Primary Contingent Name of beneficiary
Percentage
Social Security no.*
Relationship to applicant Date of birth
%
Street address
City
State ZIP code
Phone no.
Beneficiary type Primary Contingent
Name of beneficiary
Percentage
Social Security no.*
Relationship to applicant Date of birth
%
Street address
City
State ZIP code
Phone no.
Beneficiary type Primary Contingent
Name of beneficiary
Percentage
Social Security no.*
Relationship to applicant Date of birth
%
Street address
City
State ZIP code
Phone no.
Beneficiary type Primary Contingent
Name of beneficiary
Percentage
Social Security no.*
Relationship to applicant Date of birth
%
Street address
City
State ZIP code
Phone no.
Total percentages should add up to 100%. If the total percentages add up to less than 100%, the remaining percentage will be paid in equal shares to all named beneficiaries to total 100%. If the total percentages add up to more than 100%, each named beneficiary’s share will be reduced equally to total 100%. If no percentages are indicated, the proceeds will be divided equally. If no primary beneficiary survives, the proceeds will be paid to the contingent beneficiary(ies) listed above. Beneficiaries may be changed by the insured’s written notice to his or her employer.
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STERLING ESTATES 2023 BENEFITS GUIDE
* Anthem is required by the Internal Revenue Service to collect this information.
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