An Anthem application will need to be completed if you wish to enroll in the Medical, please complete the following:

• Section 1 - Name, date of birth, social security number, address, sex, and marital status
• Section 2 - Select new enrollment
• Section 3 - Select Blue Access PPO ( 500 or 1,000 Deductible plans) or Blue Access PPO HSA (2800 HSA plan). Either add the plan name into the document if you have a PDF editor or add the plan into the email when you submit your completed forms. Also, please select which coverage tier you are electing: employee only, employee spouse, employee child(ren), or family
• Section 4 - If enrolling dependents and/or spouse please complete with their information. Include name, date of birth, and social security number
• Section 7 - Please sign and date

If you are WAIVING medical coverage:

• Please complete Section 8 of the Anthem application, sign, and date

A Guardian application will need to be completed if you wish to enroll in the dental, vision, supplemental life, accident, critical illness and/or hospital indemnity, please complete the following (Application is at the end of the Guardian Enrollment Kit):

• Page 1 - Complete About You Section. please include name, date of birth, address, social security number, and gender
• Page 1 - Complete About Your Family. Please include the information of spouse and/or dependent child(ren) you plan to cover on the plan
• Page 2 - Dental Coverage Selection
• Page 2 - Vision Coverage Selection
• Page 3 - Life Beneficiary Designation
• Page 4 - Supplemental Life Selection for employee, spouse, and child(ren)
• Page 5 - Beneficiary designation if electing supplemental life. STD and LTD are already checked as you will enroll automatically since it is employer paid. Please select if you are enrolling in the Critical Illness
• Page 6 - Accident Coverage Selection and beneficiary designation
• Page 7 - Hospital Indemnity Selection
• Page 7- Sign and date if you elect any coverages offered by Guardian

If you are only enrolling in the employer paid life, LTD, and STD please complete page 1, page 3, and sign on page 7 of the Guardian application.

QUESTIONS:

EMAIL

USHRRelatecareBenefits@relatecare.com

RETURN COMPLETED FORMS TO

USHRRelatecareBenefits@relatecare.com



IMMEDIATELY – NO LATER THAN 5/25/2022 @ 4:00PM EST