X hits on this document

14 views

0 shares

0 downloads

0 comments

6 / 7

Signatures — Required

HIV TESTING PROHIBITED: California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance.

REQUIREMENT FOR BINDING ARBITRATION The following provision does not apply to class actions:

IF YOU ARE APPLYING FOR COVERAGE, PLEASE NOTE THAT ANTHEM BLUE CROSS AND ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY REQUIRE BINDING ARBITRATION TO SETTLE ALL DISPUTES INCLUDING BUT NOT LIMITED TO DISPUTES RELATING TO THE DELIVERY OF SERVICE UNDER THE PLAN/POLICY OR ANY OTHER ISSUES RELATED TO THE PLAN/POLICY AND CLAIMS OF MEDICAL MALPRACTICE, IF THE AMOUNT IN DISPUTE EXCEEDS THE JURISDICTIONAL LIMIT OF SMALL CLAIMS COURT. It is understood that any dispute including disputes relating to the delivery of services under the plan/policy or any other issues related to the plan/policy, including any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. THIS MEANS THAT YOU AND ANTHEM BLUE CROSS AND/OR ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY ARE WAIVING THE RIGHT TO A JURY TRIAL FOR BOTH MEDICAL MALPRACTICE CLAIMS, AND ANY OTHER DISPUTES INCLUDING DISPUTES RELATING TO THE DELIVERY OF SERVICE UNDER THE PLAN/POLICY OR ANY OTHER ISSUES RELATED TO THE PLAN/POLICY.

Signature of applicant/parent or legal guardian

Today’s date

Signature of applicant’s spouse/domestic partner

Today’s date

X

X

Signature of applicant’s dependent age 18 or over

Today’s date

Signature of applicant’s dependent age 18 or over

Today’s date

X

X

Send your completed application and payment to: PPO plan:

Oleg Skurskiy 18375 Ventura Blvd. # 226 Tarzana , CA 91356

Anthem Blue Cross Life and Health Insurance Company P.O. Box 9063 Oxnard, CA 93031

HMO plan: Anthem Blue Cross P.O. Box 9051 Oxnard, CA 93031

Fax: 818-776-9865

Agent information and declaration

To the best of my knowledge, the information on this application is complete and accurate. I have explained to the applicant, in easy-to-understand language, the risk to the applicant of providing inaccurate information and the applicant understands the explanation. I understand that if I willfully make any false representations I shall, in addition to any applicable penalties or remedies available under current law, be subject to a civil penalty of up to $10,000.

Signature of agent

Print agent name

Agent no.

X

Oleg Skurskiy

JNHQQRNRSY

FOR ANTHEM BLUE CROSS ONLY

Group no.

Agent no.

Effective date

Pre-exist

Area

By

Date

2 of 2

Document info
Document views14
Page views14
Page last viewedTue Dec 06 09:08:35 UTC 2016
Pages7
Paragraphs203
Words2054

Comments