 |
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 |
 |
|
Employer
Guidelines |
Employer Checklist
