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Affiliated Companies Please have business owner, accountant or attorney complete and sign below. The Health Insurance Portability and Accountability Act states that all persons treated as a single employer under subsection (b), (c), (m), or (o) of section 414 of the Internal Revenue Code shall be considered one employer. Please list below all affiliates that would qualify as one employer under the above referenced section of the Internal Revenue Code. Name of Employer Group Name of Business Entity Employer Federal Tax ID Number (FEIN) 1. 2. 3. 4. 5. 6. 7. I certify that the above listed business entities are considered as one employer under section 414 of the Internal Revenue Code. Signature Date Relationship to company (please check one of the following): Owner Accountant for employer Attorney representing employer For more information regarding Section 414, please refer to: http://www.fourmilab.ch/ustax/www/t26-A-1-D-I-B-414.html In Indiana: Anthem Blue Cross and Blue Shield is a trade name of Anthem Insurance Companies, Inc. In Kentucky: Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, Inc. In Missouri: Anthem Blue Cross and Blue Shield is the trade name RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance Life InsuranceCompany (HALIC) and HMO Missouri, Inc. use to do business in most of Misso uri. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. Life and disability products are underwrit ten by Anthem Life Insurance Company (ALIC).RIT and certain affiliates only p rovide administrative services for self-funded plans and do not underwrite benefits. In Ohio: Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. In Wisconsin: Blue Cross Blue Shield of Wisconsin (“ BCBSWi” ) underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (“ Compcare” ) underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Rev. 7/06 ® Registered marks Blue Cross and Blue Shield Association.
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