New York Small Group Employer Benefit Plan Change Form For Groups Of 1-100 - Anthem

New York

Small Group Employer Benefit Plan Change Form

For Groups of 1–100

1

Section 1: Group information

Group name

Effective date (MM/DD/YYYY) Group no.

Employer tax ID no. (required)

Section 2: I have demographic changes to my current plan. Please update the following:

Change phone no. to

Change group address to

Change primary group contact to

Change primary email address to

Add group contact

Other

Section 3: I have probationary-period/waiting-period changes to my current plan. Please update the following:

New hire

Date of hire (DOH)

First of month following 30 days

30 days

45 days

60 days

90 days

2

3

First of month following DOH

First of month following 60 days

1 month

2 months

Day following completion of waiting period/probationary period

3

Rehired

Date of hire (DOH)

First of month following 30 days

30 days

45 days

2

60 days

90 days

3

First of month following DOH

First of month following 60 days

1 month

2 months

Day following completion of waiting period/probationary period

3

Section 4: Medical/Vision/Dental benefit change authorization

Fill out this section if you would like to choose a plan that was not shown in your renewal options. Please note your benefit selection(s) below and submit your

CURRENT NYS45, 941 Form, a current weekly or bi-weekly payroll and a signed quote.

If you want to accept the renewal coverage we already proposed, no action is needed.

I would like to make the following benefit plan change(s) during my renewal:

Current plan name

Current contract code

Renewal plan name

Renewal contract code

Section 5: Riders — Check all that apply

Domestic Rider

Age 29 Rider

Section 6: Disclaimer language

Certification

By signing below, I certify that all statements contained in this form are true and accurate to the best of my knowledge. I further certify that I am an officer or

owner of the business and duly authorized to execute this certification on behalf of the business.

INSURANCE FRAUD STATEMENT: Any person who knowingly and with intent to defraud any insurance company or other person files an application for

insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact

material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars

and the stated value of the claim for each such violation.

Company officer signature

Printed name

X

Title

Group no.

Date (MM/DD/YYYY)

1 A small group must have at least one active full-time equivalent employee that meets the definition of employee in 42 U.S.C. 300gg-91(d)(5) but no more than

100 employees. A small group can consist of one non–spouse employee plus the business owner; a group of 100 would consist of the business owner plus 99 employees.

2 45 days is the maximum waiting period allowed for Healthy New York coverage.

3 The option, “Day following completion of waiting period/probationary period”, is required for 90–day waiting period.

SG_OHIX_NYBS_DC (1/17)

Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

46643NYEENEBS Rev. 5/16

1608532 46643NYEENEBS 2017 OHIX Demo Change App Prt FR 05 16