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CSA EIA Health Anthem Blue Cross Benefit Election Form Forty-niner Shops, Inc. Effective Date: January 1, 2020, MEMBER ENROLLMENT OR CHANGE COMPLETE IN FULL Name (Last, First, MI):Social Security
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To fill out the CSAC EIA Health Anthem form, follow these steps:
02
Start by providing your personal information, such as your name, date of birth, and contact details.
03
Fill in your employment information, including your current employer's name and contact information.
04
Provide your health insurance information, such as the policy number and insurance company's name.
05
Answer the questionnaire about your health history, including any pre-existing conditions or previous treatments.
06
Make sure to read and understand the terms and conditions section before signing the form.
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Review the completed form for accuracy and ensure all required fields are filled correctly.
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Once you have verified the information, sign and date the form.
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Make a copy of the filled-out form for your records and submit the original to the appropriate authority or entity.

Who needs csac eia health anthem?

01
CSAC EIA Health Anthem is needed by individuals who are eligible for coverage under the California School Employees Association (CSAC) Employee's Insurance Association (EIA) health insurance program.
02
This may include current or retired employees of California public schools or community colleges, as well as their eligible dependents.
03
Those who wish to enroll in the CSAC EIA health insurance or make changes to their existing coverage may need to fill out this form as part of the application or update process.
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CSAC EIA Health Anthem is a health insurance plan offered by the California State Association of Counties Excess Insurance Authority.
Employees of counties in California that are covered under the California State Association of Counties Excess Insurance Authority health insurance plan are required to file CSAC EIA Health Anthem.
To fill out CSAC EIA Health Anthem, employees need to provide personal and dependent information, select desired coverage options, and sign the necessary consent forms.
The purpose of CSAC EIA Health Anthem is to provide health insurance coverage to employees of counties in California and their dependents.
CSAC EIA Health Anthem requires information such as personal details, dependent information, coverage options, and consent forms.
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