Anthem Enrollment Application
Social Security no.* (required)
Section H: Waiver/Declining coverage Medical coverage Medical coverage declined for — check all that apply: Reason for declining coverage — check all that apply:
Myself
Spouse/domestic partner
Dependent(s)
Covered by spouse’s/domestic partner’s group coverage Enrolled in other insurance — Please provide company name and plan: __________________________________________________ Enrolled in individual coverage Spouse covered by employer’s group medical coverage Medicare/Medicaid/VA Other — please explain: ___________________________________ No coverage
Dental coverage Dental coverage declined for — check all that apply: Reason for declining coverage — check all that apply:
Myself
Spouse/domestic partner
Dependent(s)
Covered by spouse’s/domestic partner’s group coverage Enrolled in other insurance — Please provide company name and plan: __________________________________________________ Enrolled in individual coverage Spouse covered by employer’s group medical coverage Medicare/Medicaid/VA Other — please explain: ___________________________________ No coverage
Vision coverage Vision coverage declined for — check all that apply: Reason for declining coverage — check all that apply:
Myself
Spouse/domestic partner
Dependent(s)
Covered by spouse’s/domestic partner’s group coverage Enrolled in other insurance — Please provide company name and plan: __________________________________________________ Enrolled in individual coverage Spouse covered by employer’s group medical coverage Medicare/Medicaid/VA Other — please explain: ___________________________________ No coverage
Life coverage † Life/AD&D coverage declined for:
Myself Spouse, Domestic Partner and dependent coverage not available if life coverage is waived/declined. Dependent Life coverage declined for:
Spouse/domestic partner and dependents
Short Term Disability coverage declined for: Long Term Disability coverage declined for: Supplemental/Voluntary coverage declined for:
Myself Myself Myself
Supplemental/Voluntary Dependent Life coverage declined for: Voluntary Short Term Disability coverage declined for: Voluntary Long Term Disability coverage declined for: Reason for declining coverage — check all that apply:
Spouse/domestic partner and dependents
Myself Myself
Life/AD&D declined for religious reasons Do not elect to enroll in Dependent Life Do not elect to enroll in Supplemental/Voluntary coverage Do not elect to enroll in Supplemental/Voluntary Dependent Life coverage
Do not elect to enroll in Voluntary Short Term Disability Do not elect to enroll in Voluntary Long Term Disability
† I hereby certify that I have been given the opportunity to apply for the available group life benefits offered by my employer, the benefits have been explained to me, and I and/or my dependent(s) decline to participate. Neither I nor my dependent(s) were induced or pressured by my employer, agent, or life carrier, into declining this coverage, but elected of my (our) own accord to decline coverage. I understand that if I wish to apply for such coverage in the future, I may be required to provide evidence of insurability at my expense. Sign here only if you are declining coverage. Signature of applicant X Printed name Social Security no. Date (MMDDYYYY)
17 STERLING ESTATES 2023 BENEFITS GUIDE
* Anthem is required by the Internal Revenue Service to collect this information.
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