Affidavit of Dependency for Indiana Group Coverage

AFFIDAVIT OF DEPENDENCY FOR INDIANA GROUP COVERAGE

Subscriber Name: Subscriber Identification Number: Group Number:

This affidavit should be executed, notarized and submitted along with an enrollment application if you are applying for coverage for a child who is:  A married stepchild or a married child subject to legal guardianship, up to age 24, who depends on the subscriber for more than fifty percent (50%) of the child’s support; or  An unmarried or married grandchild or other blood relative, up to age 24, who depends on the subscriber for more than fifty percent (50%) of the child’s total support.

I, ______(“Subscriber”) after being first duly sworn, depose and attest to the following:

 I am at least eighteen (18) years of age and I am mentally competent to contract;

 I am applying for coverage for ______(name), who is my ______(relationship);

 I provide more than fifty percent (50%) of the support for the child named above;

 I understand that if this dependent ceases to be an eligible dependent, I am required to submit an Application for Change within 31 days of the termination of the dependency, and the coverage for the dependent will cease at the end of the period for which premiums or administrative fees have been paid.

I certify, under penalty of perjury, that the foregoing is true and correct.

______Subscriber Signature

Signatures must be notarized.

STATE OF ______

COUNTY OF ______

On this _____ day of ______, 20___, before me personally appeared the above named ______, to me known to be the person described herein, and who executed the foregoing, and swore to its truth.

Before me, ______Notary Public Signature and Commission Exp. Date

Anthem Use Only - DCN:

Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

11/2007