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.
- Complete, sign and date the “Agent’s Attestation” section of the Employer Application (including COBRA/FMLA/Cal-COBRA Questionnaire, if applicable).
- Review all forms to ensure that Employee Applications are completed with signatures and dates. Note: Incomplete forms may be returned, which could delay
Submit all necessary forms and documentation, including:
- Copy of Agent’s quote (based upon final enrollment).
- Waivers from all employees not electing coverage (Proof of coverage may be required).
- Copy of company’s most recent Quarterly State Tax Withholding Report.
- Indicate on the document current employment status for each employee listed; full-time, part-time or terminated.
- Payroll may be required for new hires not listed on the Quarterly State Tax Withholding Report.
- An Eligibilty Statement will be required for any officers/owners not on the quarterly wage report.
- If “take-over coverage,” a copy of the prior carrier’s last month’s group premium statement.
- Copy of last month's prior carrier's group premium statement must be provided for all products elected.
- A completed Electronic Debit Payment form for 100% of the first month’s premium, payable to Anthem Blue Cross (Anthem), along with a voided check. (If electronic debit is not agreed to, a company check may be accepted, subject to additional processing time.)
- Completed Conditions of Enrollment Start-Up Companies/PEO Spin-Off Groups (if applicable).
- If applicable, include a completed Premium Only Plan (P.O.P.) enrollment form and a separate check in the amount of $125 payable to Anthem Blue Cross (Anthem).
- Broker Licensing: Online Agent Appointment Link
- Direct Deposit Form - Effective 5/1/2015 (Current)
|After approval, prior carrier termination letter must be submitted by the employer or broker.|
For other useful for older documents, please refer to the Forms database.
Important Reminder: To help your client comply with ACA requirements, provide a copy of the appropriate Summary of Benefits and Coverage (SBC) to each employee at the Enrollment Meeting, via email or by posting on an internal company website. For the most recent information regarding Anthem Blue Cross SBCs, please go to the
or contact your Word & Brown Representative.