Anthem Senior Advantage

NEW GROUP Anthem Senior Advantage Employer Group Quote Sheet Proposed Effective Date / 01 /04 Agent: Account Executive: Martiese Head Agent’s Phone # 216-573-4663 Agents’s Mail Code VS1-621 E-mail: [email protected]

The effective date of coverage is the first day of a month. The month may be up to 3 months into the future. The effective date can never be prior to the signature date on the Enrollment Form. Group Name

Address City State Zip

Retiree Benefits Decision Maker

Billing Contact

Broker

Is Anthem the Exclusive Medicare + Choice Program Offered? Yes No

If Anthem Medicare Supplemental is offered which Plan(s) A – J?

# of Eligibles

Check all delivery systems in which retirees reside and provide # of eligibles in each Health Service Area by County:

 Akron  Cincinnati  Columbus  Cleveland  Dayton  Warren / Youngstown Medina Brown Franklin Cuyahoga Butler Columbiana Portage Clermont Madison Geauga Darke** Mahoning Summit Hamilton Union Lake Greene Trumbull Lorain Miami Stark Montgomery Preble Shelby Warren

 Louisville  Northern Kentucky Jefferson Boone **only certain zip Oldham Kenton codes eligible Campbell

Who is the commercial carrier? Who is the commercial agent (if applicable)? Number of commercial actives Electronic Reconciliation: Yes No (over) NEW GROUP Comments/Special Instructions:

Please quote the following Ohio Choice Select Custom options: Kentucky Choice Select Custom

Send copy of quote to: ASA Representative Commercial Group Rep

Sales Agent Martiese Head Date: Signature: Retiree Benefits Date: Decision Maker Signature:

FOR INTERNAL USE ONLY Approved: Yes No Rate(s): Ohio Kentucky Comments Choice Select Custom

Date: Signature:

(over)