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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 [email protected]. Mail, fax (219-769-4563), or drop off your completed forms to NISEC Administrative Office, 2150 West 97th Place, Crown Point, IN 46307.
