|
Home  Employer Checklist Policy
Employer Checklist
Please make sure you include the following items when
submitting your Small Group’s application:
A copy of your agent’s
quote, based on final enrollment figures
The Small Group Employer
Application, form # 0003348
The Small Group Employee
Applications:
Groups of 2 – 50, form # 0003345
Groups of 11 – 50, form # 0003347
NOTE: Enrolling employees and their dependents must complete
and sign the application. Employees and dependents declining coverage
must complete Sections 2 and 4 and sign the application.
Most recent DE-6 Quarterly
State Tax Withholding Statement
Sole Proprietors, Partners
and Corporate Officers Statement, form # ME 8054, for those not appearing
on form DE-6
Cal-COBRA/COBRA/FMLA Questionnaire,
if applicable (included in form #0003348)
Copy of last premium statement
from former carrier, if applicable
Integrated MediComp Workers’
Compensation Application, form # IS 2343, if applicable
A company check for 100
percent of the first month’s medical, dental and life premiums
payable to Anthem blue cross of California
|
