Application For Group Insurance — CHEIBA Trust — Basic Life
SECTION 1: EMPLOYEE INFORMATION
Name of Institution
HOME OFFICE USE ONLY
Billing unit number
Coverages applying for (if applicable)
Reference number (if applicable)
Life/AD&D Dependent Life
Payroll no. (if applicable)
Social security no.
Date of birth
____% Emp paid
Date of employment
Hourly Weekly Biweekly Monthly Semimonthly Yearly
Hours worked per week excluding overtime
Primary beneficiary name (if married woman, give first, married and maiden name) Birthdate
Secondary beneficiary name (if married woman, give first, married and maiden name) Birthdate
SECTION 2: EMPLOYEE SIGNATURE - Sign below if you are applying for coverage
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 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.
I certify that I meet the eligibility requirements of the employer. I understand that if I am not actively at work on the date my insurance would Amount____________________
otherwise become effective, the insurance will not become effective until the second successive day I am actively at work thereafter.
LTD Effective Date
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.
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Life and Disability products underwritten by Anthem Life Insurance Company. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.
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