Get Anthem Employment Verification

Employment Verification Form Anthem Blue Cross and Blue Shield requires that all groups requesting group health insurance as defined under RSA 420-G that have not filed the New Hampshire Quarterly Tax and Wage Report and have not yet filed Federal income taxes to verify employment and business status. Name of Proprietor Principal Business or Profession Business Name The proprietor named above certifies that s/he is gainfully and actively employed and working a minimum of 15 hours per week in the business named above. This same requirement applies to any employees for whom coverage is being requested* The proprietor further acknowledges that this information will be used by Anthem Blue Cross and Blue Shield in determining business validity and any attempt to knowingly provide inaccurate information may result in the termination of the Anthem Blue Cross and Blue Shield policy retroactive to the policy issue date and prosecution under state and federal fraud laws. Coverage shall not go into effect until the underwriting requirements of Anthem Blue Cross and Blue Shield have been accepted Signature of Proprietor Date ENHFR6851A 4/09 of the Blue Cross and Blue Shield Association* ANTHEM is a registered trademark of Anthem Insurance Companies Inc* The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association*. Name of Proprietor Principal Business or Profession Business Name The proprietor named above certifies that s/he is gainfully and actively employed and working a minimum of 15 hours per week in the business named above. This same requirement applies to any employees for whom coverage is being requested* The proprietor further acknowledges that this information will be used by Anthem Blue Cross and Blue Shield in determining business validity and any attempt to knowingly provide inaccurate information may result in the termination of the Anthem Blue Cross and Blue Shield policy retroactive to the policy issue date and prosecution under state and federal fraud laws. This same requirement applies to any employees for whom coverage is being requested* The proprietor further acknowledges that this information will be used by Anthem Blue Cross and Blue Shield in determining business validity and any attempt to knowingly provide inaccurate information may result in the termination of the Anthem Blue Cross and Blue Shield policy retroactive to the policy issue date and prosecution under state and federal fraud laws. Coverage shall not go into effect until the underwriting requirements of Anthem Blue Cross and Blue Shield have been accepted Signature of Proprietor Date ENHFR6851A 4/09 of the Blue Cross and Blue Shield Association* ANTHEM is a registered trademark of Anthem Insurance Companies Inc* The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association*. Name of Proprietor Principal Business or Profession Business Name The proprietor named above certifies that s/he is gainfully and actively employed and working a minimum of 15 hours per week in the business named above. This same requirement applies to any employees for whom coverage is being requested* The proprietor further acknowledges that this information will be used by Anthem Blue Cross and Blue Shield in determining business validity and any attempt to knowingly provide inaccurate information may result in the termination of the Anthem Blue Cross and Blue Shield policy retroactive to the policy issue date and prosecution under state and federal fraud laws. Coverage shall not go into effect until the underwriting requirements of Anthem Blue Cross and Blue Shield have been accepted Signature of Proprietor Date ENHFR6851A 4/09 of the Blue Cross and Blue Shield Association* ANTHEM is a registered trademark of Anthem Insurance Companies Inc* The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association*.