| | Anthem Forms |
| | All forms and plan descriptions are in portable document format (PDF).
 |
| | Some forms are available for download in Spanish.
Click the language to download the form. |
| | Form Type: Medical |
| | Form Name | Form Description
|
| |
Affidavit of Common-law Marriage
English
Spanish
(85 kb) | For adding a common-law spouse and his/her dependents to policy |
| |
BeneFits Quick Reference Guide
English
() | This chart is designed to help employers begin the selection process. |
| |
COBRA or State Continuation of Coverage Application
English
Spanish
(110 kb) | For requesting continuation of health coverage when a member/dependent coverage is terminated. |
| |
Colorado small group benefit changes effective April 1, 2009
English
Spanish
() | Colorado small group benefit changes effective April 1, 2009. |
| |
Continuity of Care Form
English
(154 kb) | To avoid disruption for a member currently under a provider's care; approved on a case by case basis up to 90 days in advance. |
| |
Electronic Funds Transfer (EFT) Authorization Form
English
() | Used to withdraw premium payments and any
other related amounts permitted by the Employer Master Contract from the Group's account. |
| |
Employee Enrollment Supplemental - EmployeeElect
English
() | Used to enroll employees in EmployeeElect Health Plans. This form is to accompany the Colorado Uniform Employee Application for Small Group. |
| |
Employee Enrollment Supplemental Form - BeneFits
English
() | Used to enroll employees in BeneFits Health Plans. This form is to accompany the Colorado Uniform Employee Application for Small Group. |
| |
EmployeeElect Plan Grid
English
() | A side by side comparison of all EmployeeElect health plans. |
| |
Employer Enrollment Application - BeneFits
English
() | Employer group application for the Benefits plans. |
| |
Employer Enrollment Application - Employee Elect
English
() | Employer group application for enrolling in Employee Elect Plans. |
| |
Mentally or Physically Disabled Dependent Enrollment Request
English
Spanish
(95 kb) | Submit with application for group coverage if you have an overage physically or mentally disabled dependent. |
| |
Overage Dependent Enrollment Request
English
Spanish
(94 kb) | For enrollment/continuation of coverage for overage dependents. |
| |
Risk Questionnaire
English
(56 kb) | For submission with a group's quote/proposal request and Employer Application, for groups of two or more. |
| |
Standard Industrial Classification (SIC) Codes
English
() | Standard Industrial Classification (SIC) Code: Small Group Rating Factors |
| |
Subscriber Submitted Claim
English
(90 kb) | Subscriber Submitted Claim |
| |
Underwriting Guideline
English
() | Overview of the Underwriting Process |
| |
User Agreement & Employer Registration Form
English
() | Agreement between Anthem and User of Anthem Application |
| | Form Type: Life and Disability |
| | Form Name | Form Description
|
| |
Group Life Insurance Conversion Application
English
(17 kb) | Applying for individual whole life insurance due to termination of employment. |
| |
Voluntary Group Life Enrollment Form
English
(34 kb) | Applying for any voluntary insurance coverage. |
| | Form Type: Dental/Vision |
| | Form Name | Form Description
|
| |
Employer Application/Change Form
English
(154 kb) | Application and change form for employer's group health, dental and/or vision coverage. |
| |
