Employee Addition Application
Employee Application
Blue Cross Authorized Agent
Blue Cross Administrative Manual

What is the simplest, easiest way to get onto my New Employers Blue Cross/Anthem Group Health Coverage?

Complete and send us an employee application  2015.   Please email us to verify the latest forms.

How do I know how much my premium contribution will be?

Send us your Census information and we can send you an “Employee Worksheet” showing your contribution and all plans available to you.

Please double check with your Employer if Group Dental, vision and Life Coverage is being offered.  We can get you the pricing on that too.  If not, Individual Dental, vision and Life Coverage are available.

Where can I get details of what each plan covers?

Blue Cross Small  Group 
Detailed Plan Brochures
Summary of Features

Blue Cross SBC
Summary of Benefits
fact sheet



Find a Doctor, Hospital and other Providers

If my Employer has a POP Section 125 Plan, does that make my portion of the Premium pre tax?

Any Other pointers, you can give me?

• Use black or blue ink and print clearly and legibly.
• Include your Small Group number at the top of the application.
• Make sure all required areas of the form are completed.
• If an HMO plan is selected, a primary medical group (PMG) or independent practice association (IPA) and office number are required.
• If Dental Net is selected, a dental office and office number must be selected.
• All information in section 3 must be completed.
• Social Security or ID number(s) are required.
• The employee must either enroll or decline coverage for all eligible dependents.
• Information on previous coverage is critical; be sure to submit proof of prior coverage (if applicable) and provide a copy of a Medicare ID card (if applicable).
• The last page of the application must be signed and dated by the employee.
• Employees who request life insurance must name a beneficiary.
• Incomplete applications may be returned, which will delay the coverage effective date.
(Adm. Manual Page 17)

Where can I get exact details on the rules to enroll?

What about late enrollees, Open Enrollment, Special Enrollment?

I have a pre-existing condition, what happens?

Why do premiums keep increasing?

What if I want coverage NOW, without waiting for my completion of the Probation (Waiting) Period?

COBRA from a prior employer?

Short Term – Temporary Plans

What if my dependents or I do not want the coverage?

Please complete Section 4 waiver section.

Section 4 of Application - Employee - New Hire
Click to enlarge

Main Blue Cross & Related Pages



E Submit     A new & faster way for groups & brokers to submit applications, changes, and terms to enrollment

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