Anthem Blue Cross

enrollment kit - Anthem blue cross (dental & Vision)

This checklist is provided as a guide. The carrier may require additional items and documentation. Please refer to the carrier's underwriting guidelines for a complete list of requirements. Please use the latest version of forms.
 
Our goal is to process your new group enrollment easily and efficiently in order to provide you and your client with a quick approval.  The following list outlines Anthem Blue Cross’s case submission requirements​​.
 
  • A copy of agent’s quote (based on final enrollment).
  • The most current Employer Application 
  • The most current Employee Application -  for all employees enrolling.
  • Declinations from all employees declining coverage (sections 2 and 4 of the employee application).
  • A copy of the company’s most recent Quarterly State Tax Withholding Statement†† with the current employment status of all employees listed.*
  • If “takeover” coverage, a copy of the Prior Carrier’s last month’s group premium statement.
  • COBRA/FMLA/Cal-COBRA Questionnaire​; the last billing statement listing COBRA/Cal-COBRA subscribers.
  • A company check, or completed Check by Fax form (Form #12238CABEN), for the first month’s applicable coverage(s) made payable to “Anthem Blue Cross”.
  • Submission is 100% of the premium with application.
  • Employer’s Statement of Understanding​​​.​
 
  • Broker Licensing: Broker Appointment Process
  • ​Agent Direct Deposit Au​​​th​orization - Effective 5/1/2015 ​​​(Current)​

††DE-9C not required on Specialty only sales, including standalone new sales and up sells on existing Medical cases
 
*See Section 3, California Underwriting Business Requirements for the Sole Pro​prietor, Partner, or Corporate Officer Statement​ not appearing on the DE-9C​​. See section 3, California Underwriting Business Requirements for the

 
​After approval, prior carrier termination letter must be submitted by the employer or broker.​
 ​​​​

For other useful or older documents, please refer to the Forms database.
  • Broker Electronic Funds Transfer (EFT) Enrollment and Maintenance Form
    • Anthem Blue Cross

    • form #53791CABENABC

    • Effective date: 05.01.2015

  • Sole Proprietor, Partner, or Corporate Officer Eligibility Statement
    • Anthem Blue Cross

    • form # N/A

    • Effective date: 01.01.2019

  • New Group Submission Checklist - Dental
    • Anthem Blue Cross

    • form # N/A

    • Effective date: 01.01.0001

  • Statement of Understanding for ACA Small Groups 1-100
    • Anthem Blue Cross

    • form # N/A

    • Effective date: 01.01.2016

  • Broker Appointment Process
    • Anthem Blue Cross

    • form # N/A

    • Effective date: 07.01.2020

  • Electronic Funds Transfer (EFT) Authorization Form For Small Group Initial & Recurring Payments
    • Anthem Blue Cross

    • form # N/A

    • Effective date: 02.15.2021

  • Employer Application
    • Anthem Blue Cross

    • form # N/A

    • Effective date: 01.01.2021

  • Employee Enrollment Application
    • Anthem Blue Cross

    • form # N/A

    • Effective date: 01.01.2021

  • Cal-COBRA/COBRA And Medicare Survey
    • Anthem Blue Cross

    • form # N/A

    • Effective date: 01.01.2021