Anthem Enrollment Application
Social Security no.* (required)
If you live in AZ, CA, ID, LA, NM, NV, TX, WA, WI and your spouse is not 50% or more beneficiary, your spouse needs to sign below. In CA, NV, and WA, Spouse also includes your registered Domestic Partner. Spousal consent for community property states only (Note: The insurance company is not responsible for the validity of a spouse’s consent for designation.) If you live in a community property state (AZ, CA, ID, LA, NM, NV, TX, WA, and WI), your state may require you to obtain the signature of your spouse if your spouse will not be named as a primary beneficiary for 50% or more of your benefit amount. Please have your spouse read and sign the following. I am aware that my spouse, the Employee/Retiree named above, has designated someone other than me to be the beneficiary of group life insurance under the above policy. Spouse authorization, if applicable I hereby consent to such designation and waive any rights I may have to the proceeds of such insurance under applicable community property laws. I understand that this consent and waiver supersedes any prior spousal consent or waiver under this plan.
Spouse/Domestic Partner name
Date (MMDDYYYY)
Spouse/Domestic Partner signature X
Spouse sign here to waive community property rights
6. Group Supplemental Health plans — Refer to the summary of benefits for coverage options offered. Select all that apply. Accident Member accident coverage — select one: Employee only Employee + Spouse/Domestic Partner Employee + child(ren) Family Complete the following if there is more than one Voluntary Accident plan design offered: Contract code for plan elected: ________________ Critical Illness Member critical illness coverage — select one: Employee only Employee + Spouse/Domestic Partner Employee + child(ren) Family Contract code for plan elected: ________________ Employee coverage amount: ________________ Will all eligible individuals applying for Critical Illness coverage, when such coverage is to become effective, be enrolled in comprehensive health benefits from an individual or group health insurance policy or an HMO or employer plan providing for essential health benefits? Yes No Complete the following if you or your spouse smoked or used tobacco products in the last 12 months: (tobacco product explanation) Employee smoker — select one: Yes No If yes, type of tobacco product: __________________________________ Spouse smoker — select one: Yes No If yes, type of tobacco product: __________________________________ Hospital Indemnity Member hospital indemnity coverage — select one: Employee only Employee + Spouse/Domestic Partner Employee + child(ren) Family Will all eligible individuals applying for Hospital Indemnity coverage, when such coverage is to become effective, be enrolled in comprehensive health benefits from an individual or group health insurance policy or an HMO or employer plan providing for essential health benefits? Yes No Complete the following if there is more than one Voluntary Hospital Indemnity plan design offered: Contract code for plan elected: ________________ Group Accident, Critical Illness, and Hospital Indemnity Insurance 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.
12 STERLING ESTATES 2023 BENEFITS GUIDE
* Anthem is required by the Internal Revenue Service to collect this information.
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