Application For Group Insurance - CHEIBA Trust
FORM MUST BE FILLED OUT IN BLACK BALLPOINT OR TYPEWRITER — PLEASE PRINT AND PRESS FIRMLY
EMPLOYED BY
HOME OFFICE USE ONLY
GROUP NUMBER
BILLING UNIT NUMBER
COVERAGES
■ Life
■ Short Term Disability
■ Supplemental Life
APPLYING
■ AD&D
Amount ____________
REFERENCE NUMBER
FOR
■ Dependent Life
■ Long Term Disability
(IF APPLICABLE)
(If Applicable)
CLASS NUMBER
G.I. CODE
APPLICANT NAME (Last, First, Initial)
PAYROLL NUMBER
(IF APPLICABLE)
UNDERWRITING
UNDERWRITING
REASON
ACTION
ADDRESS (Street, City, State, Zip Code)
■ Small Group
■ Approved
■ Late Enrollee
■ Declined
SOCIAL SECURITY NUMBER
SEX
■ ______ % Employer Paid
■ Male


Excess
Initials __________
Female
Amount ______________
Date _____________
DATE OF EMPLOYMENT (Month, Day, Year)
DATE OF BIRTH (Month, Day, Year)
EFFECTIVE DATE
YES
NO
EARNINGS
■ HOURLY
■ MONTHLY
HOURS WORKED PER WEEK EXCLUDING OVERTIME
Life/AD&D
■ WEEKLY
■ SEMIMONTHLY
$ ______________________ ■ BIWEEKLY
■ YEARLY
Amount ___________________________
JOB TITLE
DEPARTMENT
Supplemental
Amount ___________________________
PRIMARY BENEFICIARY NAME (If married woman, give first, married and maiden name)
BIRTHDATE (Mo., Day, Yr.)
RELATIONSHIP
Dependent Life
Amount ___________________________
STD
SECONDARY BENEFICIARY NAME (If married woman, give first, married and maiden name) BIRTHDATE (Mo., Day, Yr.)
RELATIONSHIP
Amount ___________________________
LTD
Amount ___________________________
I hereby apply for the insurance for which I am or may become eligible under the Group Policy or Policies issued to
my Employer named above by the Anthem Life Insurance Company and hereby authorize the deduction from my
LTD Effective Date
earnings of the required contribution, if any, toward the cost of such insurance. This authorization may be revoked by
___________________________
me at any time by written notice to my Employer.
PROCESS DATE
INITIALS
I certify that I am a full-time employee of the employer named above and am compensated by salary or wages. I
understand that if I am not actively at work on the date my insurance would otherwise become effective, the
_________________
______________
insurance will not become effective until the second successive day I am actively at work thereafter.
SH
EP
It is unlawful to knowingly and intentionally provide false, incomplete, or misleading facts or information to an insurance company for the purpose of
defrauding or attempting to defraud the company with regard to an application for insurance or claim for benefits. Penalties may include imprisonment,
fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or
misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with
regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of
Regulatory Agencies or other appropriate State Insurance Regulatory Agency
DATE SIGNED
APPLICANT SIGNATURE
WAIVER OF INSURANCE
I hereby certify that I have been given an opportunity to participate in the benefits of my Employer’s
Group Insurance Plan underwritten by Anthem Life Insurance Company. The Plan has been
explained to me and I decline to participate.
It is understood and agreed that by the completion of this waiver of insurance form I forfeit my rights
to coverage under the Group Policy, and should I elect at a later date to participate in the plan, I must
furnish at my own expense, evidence of insurability satisfactory to Anthem Life Insurance Company.
DATE SIGNED
EMPLOYEE SIGNATURE
EMPLOYEE (PRINTED) NAME
EMPLOYER NAME
FORM NO. 99193
(REV. 1-01)
WHITE -Anthem Life/CANARY - Agency/PINK - Customer