nisec memorandum from: becky krumwied, fina …nisec memorandum from: becky krumwied, fina ncial...

NISEC MEMORANDUM

FROM: BECKY KRUMWIED, FINANCIAL ASSISTANCE

SUBJECT: ANTHEM BLUE CROSS BLUE SHIELD ENROLLMENT AND CHANGES

DATE:

11/8/2011 – ENROLLMENT APPLICATION FORM CHANGES

For your convenience NISEC has provided printable forms for Anthem’s health

and/or dental enrollment application (A-82) and change application (A-83).

If enrolling yourself or adding dependents, please complete the EMPLOYEE ENROLLMENT APPLICATION (A-82) on the following pages. Sign and date at the bottom of page 4.

If you are making an address and/or name change, please fill out the EMPLOYEE CHANGE FORM APPLICATION (A-83) go back to Printable Forms and make the proper form selection.

If you are cancelling any coverage for yourself or your dependents, please fill out the EMPLOYEE CHANGE FORM APPLICATION (A-83) go back to Printable Forms and make the proper form selection.

Please direct any questions regarding these forms to me via phone at 219-769-4000 extension 231, or email to bkrumwied@nisec.org. Mail, fax (219-769-4563), or drop off your completed forms to NISEC Administrative Office, 2150 West 97th Place, Crown Point, IN 46307.