700 Anthem EPO Enrollment

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Applicant Information – Step 1 of 6

Applicant Name *

First

Last

Email Address *

Your completed application copy will be sent here.

Cell Phone *

Home Phone

Social Security Number *

Date of Birth *

Gender *

Male
Female

Marital Status *

Single
Married
Domestic Partner
Widowed
Separated / Divorced

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Apt #

Are you employed a minimum of twenty (20) hours per week (on average)? *

Membership requires a minimum of 20 hours per week.

Worker Classification *

W2
K1
Schedule C

Occupation *

Employer / Business Name *

Date of Employment *

The date you started with your current employer.

Hourly Rate

Business Phone

pregnant, any of

Business Address

Business Email

Beneficiary Name *

Beneficiary Relationship *

Spouse / Partner Name

First

Last

Complete this section only if your spouse/domestic partner will be COVERED on this plan. If they are not enrolling, leave it blank.

Spouse / Partner SSN

Spouse / Partner Date of Birth

Spouse / Partner Gender

Male
Female

Spouse / Partner Email

How many child dependents are you enrolling? *

Children being covered on this plan. Do not count your spouse here — they have their own section above.

Child 1 — Name

First

Last

Child 1 — SSN

Child 1 — Date of Birth

Child 1 — Relationship

Son
Daughter

Child 2 — Name

First

Last

Child 2 — SSN

Child 2 — Date of Birth

Child 2 — Relationship

Son
Daughter

Child 3 — Name

First

Last

Child 3 — SSN

Child 3 — Date of Birth

Child 3 — Relationship

Son
Daughter

Child 4 — Name

First

Last

Child 4 — SSN

Child 4 — Date of Birth

Child 4 — Relationship

Son
Daughter

1. Heart attack, brain tumor, stroke, heart disease or heart problems? *

2. Cancer, tumor, lymphoma or any type of transplant? *

3. Any surgery or hospitalization in the last 5 years, OR currently pending, planned or recommended? *

4. Emphysema or COPD? *

5. Kidney failure, dialysis, or disorder of the liver, stomach, pancreas, colon or bladder? *

6. Seizures, epilepsy, hemophilia, sleep apnea or blood disorder? *

7. Diabetes, endocrine, autoimmune, Crohn's Disease or arthritis or pituitary disorder, growth disorder, lupus, MS, AIDS or HIV+? *

8. Currently pregnant, premature delivery or multiple births? *

9. Is anyone listed on the application taking or currently taking medications in the last 12 months? *

Details for Yes answers to questions 1–8 *

Please provide date, type and further treatment if any.

Medications taken in the last 12 months *

List name of medication, dosage and corresponding medical condition. Include diagnosis date and date of last physician visit for the condition.

Plan Tier — 700 Anthem EPO (Monthly Rate) *

Single — $1,482.95
Employee + 1 Child — $2,589.70
Employee + Spouse — $2,965.90
Family — $3,928.25

Rates effective through 06/30/2027. A $125.00 Annual Administration Fee applies at enrollment.

Requested Effective Date *

Coverage always begins on the 1st of the month. The dates offered respect the enrollment cutoff — materials must be received by the 20th of the month prior to your start date.

Previous Carrier

Payment Mode *

Monthly Automatic Check (ACH)
Quarterly E-mail Invoice

If paying quarterly, the first payment must be three (3) months’ premium.

Payer Name (if different from member)

Bank Name *

Routing Number *

Account Number *

Payment summary: Your total contribution at enrollment is your monthly rate (× 3 if paying quarterly) plus the $125.00 Annual Administration Fee. Payments received after the due date are subject to a late fee (currently $35). Chargebacks/not-authorized returns incur a $50 fee; other returned payments $35. A $75 reinstatement fee applies if coverage is terminated and reinstated. Checks are payable to A.F.I. — questions: info@fagefinancial.com • (845) 499-2255.

Broker / Representative Name

Your representative. If this is not the person helping you, they can correct it here.

Broker / Representative Email

A copy of the completed application will be sent to this address.

Are you submitting this enrollment after the 20th of the month prior to your requested effective date? *

Late Enrollment Acknowledgement *

I acknowledge that my enrollment materials were submitted after the 20th of the month prior to the effective date of coverage. I understand I may not be able to verify eligibility, and my ID card(s) may not arrive, sooner than 30 days from the start date, and that I may have to contact the carrier directly regarding out-of-pocket expenses and/or claims issues.

Consent & Authorization *

I hereby apply for Group Insurance for which I am or may become eligible. All documents and answers in this application are complete, accurate and truthful to the best of my knowledge.
If paying by ACH, I authorize A.F.I. to initiate withdrawal(s) from my bank account in such amount as needed to keep my benefits active until revoked in writing (allowing up to 30 days to act). I understand the $35/$50 returned-payment fees and that this payment plan may be cancelled at any time.
I understand I will receive an email with a secure link to review my completed application packet (Enrollment Worksheet, Health & Welfare Fund Application, Personal Health Questions, Membership Form, ACH Authorization, and Late Enrollment Acknowledgement if applicable) and sign it electronically; my electronic signature will be applied to each document and carries the same legal effect as a handwritten signature.

Broker ID

Personal Health Questions for Applicant and Dependents. You must answer ALL questions on behalf of everyone listed on this application.

700 Anthem EPO Enrollment

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