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2-50 Small Group Employer Application
2-50 Existing Small Group Employee Addition Application
Small Group Change of Coverage Application
Dental Coverage Employee Application
Small Group Benefit Modification Inquiry
Prescription Drug Claim Form
Small Group Remittance Report
Use this form to report termination of employees and/or dependents, address change for covered employees, or COBRA/Cal COBRA notifications.
Standard Enrollment/Translator's Statement
When completing the Small Group Employee Application and a translator assists you, the translator must complete this form and attach it to the application.
Patient Claim Form
When an employee receives services from a health care provider, the health care provider submits the claim directly to Anthem blue cross. However, in certain circumstances the employee may be required to submit a claim form. See page 1 of this form for instructions.
Affidavit of Domestic Partnership
If an employer offers the domestic partner eligibility option to their employees, and an employee wishes to add their domestic partner to their plan, the employee must complete and submit this form along with an Employee Application requesting enrollment.
Cal-COBRA/COBRA and Medicare Survey
In order to ensure compliance with state and federal laws, you are required to update Anthem blue cross annually with your company's Cal-COBRA or COBRA and Medicare eligibility for the upcoming year.
Small Group Required Information Checklist
Accelerated Death Benefit Attending Physician's Statement
Claim for Personal Accelerated Death Benefit
Beneficiary Claim Form & Group Policyholder's Statement
Absolute Assignment
Change of Beneficiary and/or Name
Statement of Attending Physician (Dismemberment)

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