SECTION 15 (HIPAA-CHIP) ELIGIBILITY AND ENROLLMENT FORM COMPLETE ALL OF THE FOLLOWING QUESTIONS IN THEIR ENTIRETY (Please print)

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1 I C H I P Illinois Comprehensive Health Insurance Plan STATE OF ILLINOIS COMPREHENSIVE HEALTH INSURANCE PLAN (CHIP) 400 West Monroe Street, Suite 202, Springfield, Illinois (toll-free in Illinois only) or (217) (voice) Administrator: Blue Cross and Blue Shield of Illinois (for TDD access: ) SECTION 15 (HIPAA-CHIP) ELIGIBILITY AND ENROLLMENT FORM COMPLETE ALL OF THE FOLLOWING QUESTIONS IN THEIR ENTIRETY (Please print) Applications with missing information will have to be returned 1. COVERAGE SELECTED: Check if applying for the following CHIP PLAN Optional Maternity Coverage $500 Deductible per individual ($1000 family maximum) $500 indemnity benefit CHIP PLAN (available in $500 increments not to exceed $1000 Deductible per individual ($2000 family maximum) the number shown in the Summary of Coverage CHIP PLAN under Optional Maternity $1500 Deductible per individual ($3000 family maximum) Benefits) CHIP PLAN $2500 Deductible per individual ($5000 family maximum) Number of Maternity Increments applied for 2. Full Home Address (P.O. Box NOT acceptable): Street Address City County (required) State Zip Code - (Area Code) Home Phone (Area Code) Work Phone Birth date / / Age Sex M F Social Security No. - - Marital Status Married Spouse s name Social Security No. - - Single Widowed Divorced Custodial Parent s Name (If the applicant is a minor) Social Security No Complete only if another family member is to be insured under CHIP. If more than two dependents are to be covered by CHIP, attach a copy or blank page with all of the same information for each dependent. 3a. Social Security No. - - Relationship to Applicant Birth date Age Sex M F 3b. Social Security No. - - Relationship to Applicant Birth date Age Sex M F OB-2063 Rev. 3/02 THIS FORM REPLACES ALL EARLIER VERSIONS

2 CURRENT AND PREVIOUS HEALTH INSURANCE COVERAGE INFORMATION: YOU MUST ANSWER QUESTIONS 4 THROUGH 14 FOR EACH FEDERALLY ELIGIBLE INDIVIDUAL AND DEPENDENT WHO IS TO BE COVERED UNDER CHIP. FOR EACH QUESTION, INDICATE THE NAME(S) TO WHOM EACH RESPONSE APPLIES. COPY AND ATTACH ADDITIONAL SHEETS IF NECESSARY. 4. Indicate when your most recent coverage under a group health plan or policy has or will end: IMPORTANT: If this CHIP Eligibility and Enrollment Form, and any required enclosures, are not received by the CHIP Board office within 90 days of the date shown in Question 4 above, you will not qualify as a federally eligible individual or be eligible for CHIP coverage under Section 15. You should, therefore, complete the Section 7 Eligibility and Enrollment Form. 5. Have you been covered by prior creditable coverage (health insurance) for a total of at least 18 months as of the date shown in Question 4 above? Yes No If YES, indicate the dates during which you have been covered: Beginning Date: Ending Date: Mo Day Year IMPORTANT: If you have been provided with a Certificate of Creditable Coverage as required by federal law by each of the prior plans or health insurance companies with which you have had creditable coverage without a break of more than 90 days during the past 24 months, you must include it (them) with your application. If you have not received this certificate(s), you should request one from each prior plan or employer. You do not have to wait until you have received this certificate(s) to apply for CHIP. You will, however, have to provide this or other documentation that will establish any period of such creditable coverage that you have had before we can determine if you qualify for CHIP coverage under Section Has there been any break in coverage during the period of prior creditable coverage referenced in Question 5? Yes No If YES, indicate the dates during which you have NOT been covered: From: To: From: To: 7. What type of creditable coverage did you most recently have? (Check ONLY one) Group Health Plan (or Group Health Insurance coverage) Individual Health Insurance Policy Medicare Medicaid CHIP or other State Risk Pool Federal or other Government Employees Plan Church Plan Other (Specify): 8. You MUST answer either YES or NO to each of the following questions with regard to your MOST RECENT PRIOR COVERAGE: Did your prior insurance terminate due to: End of COBRA/continuation period Yes No Non-payment of premium Yes No Cancellation/Non-Renewal by Issuer Yes No Resignation/Termination Yes No Termination of Dependent Coverage Yes No Death or Divorce of Spouse Yes No Business Closed/Bankruptcy Yes No Fraud Yes No Other Reasons: Yes No (Specify): 9. Were you (are you) eligible for continuation of coverage under COBRA or similar State continuation laws? Yes No 9a. If YES, identify the name, address and phone number of the former employer, and the name, address and phone number of the COBRA Administrator or issuer for this former employer: Name of Former Employer Name of Group Plan or Issuer Policy or Plan Number Address Address Phone Number Phone Number IMPORTANT: You must include with your application a copy of one or more letters or notices you received from a former employer and/or COBRA Administrator which will verify the beginning and ending dates of any COBRA or other continuation period you were eligible for, and a copy of a termination letter or other corroborating evidence (such as a cancelled check) that will establish when and why your continuation coverage terminated. -2-

3 9b. Provide the dates of the continuation period: From To 9c. Identify the qualifying event that made (or makes) you eligible for such continuation of coverage: Resignation or Termination Yes No Disability Yes No Death or Divorce of Spouse Yes No Reaching the limiting age Yes No Retirement Yes No Retirement of Spouse Yes No 9d. Have you exhausted (or will you soon exhaust) all continuation of coverage options available to you? Yes No If YES, indicate date continuation coverage (will be) terminated: 10. Are you currently eligible for coverage under any group health plan (other than continuation coverage as indicated in Question 9a above)? If yes, provide details below: Yes No Name of Employer, Association or Other Sponsoring Organization Group Policy or Plan Number 11. Are your currently covered by any health insurance (other than any continuation of coverage as indicated in Question 9a)? If yes, provide details below: Yes No Name of Plan or Issuer Policy or Plan Number Description of Coverage 11a. Do you intend to terminate your current health insurance coverage? Yes No 11b. Date coverage will terminate: 12. Are you eligible for Medicare? Yes No If YES, provide a copy of your Medicare ID card. 12a. If eligible for Medicare, do you have other insurance that supplements Medicare? Yes No 13. Have you applied for, or are you currently receiving, disability benefits through Social Security? Yes No 13a. If you are now receiving such benefits, provide the date on which they first began: 14. Are you receiving or approved to receive medical assistance, including Medical Assistance No Grant (MANG), from the Illinois Department of Public Aid? Yes No If YES, provide PUBLIC AID ID NUMBER(S) 15. Provide information on your current or most recent employer. If married, provide the same information for your spouse (even if the spouse is not applying for CHIP). If the applicant is a dependent, provide employment information for the dependent s parent(s), stepparents(s) and/or guardian(s): EMPLOYMENT EMPLOYER ADDRESS CITY STATE ZIP CODE TELEPHONE TERMINATION DATE (if any) Applicant: Spouse: Other: 16. You must answer all of the following questions. If the applicant is a dependent, the questions will refer to the employment of the dependent s parent(s), step-parent(s) and/or guardian(s): 16a. Are you employed or self-employed? Yes No 16b. Does your employer provide a group health plan or health insurance coverage for employees? Yes No 16c. If Yes: (i) what is the name of this plan or insurer? (ii) what is the plan or policy number? (iii) what is the anniversary date for this plan or policy? 16d. Are or were you eligible for this employer group plan or coverage? Yes No 16e. Have you applied for this employer s plan or coverage? Yes No 16f. Were you previously covered under any plan or coverage offered by this employer? Yes No -3-

4 16g. How many employees does your employer employ? 10 or less More than 50 16h. Are you married? Yes No If YES, continue with all of the remaining parts of question i. Is your spouse employed or self-employed? Yes No 16j. Does your spouse s employer provide a group health plan or health insurance coverage for its employees? Yes No 16k. If Yes: (i) what is the name of this plan or insurer? (ii) what is the plan or policy number? (iii) what is the anniversary date for this plan or policy? 16l. Are or were you eligible for this employer group plan or coverage? Yes No 16m. Have you applied for this employer s plan or coverage? Yes No 16n. Were you previously covered under any plan or coverage offered by this employer? Yes No 16o. How many employees does your spouse s employer employ? 10 or less More than If you are not eligible for any health insurance coverage or group health plan provided, offered or arranged by your or your spouse s or your parent(s) employer for reasons other than your health (e.g., temporary or part-time employment), please briefly explain why. 18. If you were previously covered under any health insurance coverage or group health plan provided, offered or arranged by an employer and are no longer covered, provide the name of the plan or issuer, plan or policy number, the date that such coverage terminated and a brief explanation as to why you are no longer eligible for coverage under that group or health plan. Name of Plan or Issuer: Plan or Policy Number: Date of Termination: Reason for Termination: Required Documentation: A) If any employer identified above does not provide, offer or arrange for health insurance coverage or a group health plan for any of its employees, you must attach a statement to that effect from the employer. B) If you are not eligible for any health insurance coverage or group health plan which is provided, offered or arranged by your, your spouse s, or your parent(s) employers, you must attach a copy of a recent rejection letter(s) you have received from each such health insurance issuer or plan stating that you are ineligible due to health reasons and a written statement from those employers verifying that you are not eligible for any health insurance coverage or group health plan for the reasons outlined in such statement. RESIDENCY INFORMATION: 19. Are you a United States citizen? Yes No If NO, are you a lawful permanent resident alien? Yes No If YES, attach a copy (front and back) of your I-151 or I-551 form (Green Card). 20. Are you currently physically residing in a place of permanent habitation within the State of Illinois which you have established as your permanent home and domicile? Yes No 20a. If YES, indicate the most recent date on which you became a permanent resident of and established your domicile in the State of Illinois with the intent of continuing to physically reside and remain present in the State of Illinois for the foreseeable future except when absent for temporary or transitory purposes. IMPORTANT: ATTACH A COPY OF YOUR CURRENT VALID ILLINOIS DRIVER S LICENSE OR ID CARD ISSUED BY THE SECRETARY OF STATE OR YOUR CURRENT RESIDENT ILLINOIS INCOME TAX RETURN (IL-1040) FOR THE PREVIOUS CALENDAR YEAR. THIS DOCUMENTATION MUST REFLECT YOUR CURRENT RESIDENTIAL ADDRESS. We may periodically require verification of residency and may require additional information or documentation or statements under oath from you when necessary to determine your residency for the entire term of any coverage that is provided by CHIP. A child or legally incompetent adult is legally domiciled in Illinois if the child and his or her custodial parent(s) or the legally incompetent adult and his or her legal guardian of the person both live in Illinois and are legally domiciled in Illinois. -4-

5 21. The premium will be paid by (check ONE) Monthly Bank Draft Quarterly Semiannually If you wish to pay your CHIP premium monthly, it can only be done through an automatic bank service plan or draft arrangement, and you must enclose two months premium. In that case, we will send you a bank authorization form to complete which authorizes us to automatically draft your bank account on a monthly basis. You are not required to remit any premium with this application. Any premium payments made prior to final approval of this application will be returned uncashed. If it appears that, based on your application, you qualify for Plan coverage under Section 15, you will be sent a certified letter offering you the opportunity to enroll, which will include the amount and form of the initial guaranteed premium payment you will be required to remit at that time. I declare that I am not currently covered under the Illinois Comprehensive Health Insurance Plan, Medicare, Medical Assistance provided by the State of Illinois, any group health plan, or any health insurance coverage except as disclosed on this application, and that the statements and answers in this application are full, complete and true to the best of my knowledge and belief. Any coverage provided by this state health benefits risk pool will be based on the information in this application, a copy of which will be attached and made part of any benefit booklet which may be issued to me. I understand and agree that no plan coverage will be effective unless and until guaranteed payment for the full initial premium has been received and honored and all other requirements have been completed, received and approved by the Illinois Comprehensive Health Insurance Plan. I further understand that if I obtain or become eligible for any group health plan, health insurance coverage, Medicare, or medical assistance or move outside the State of Illinois, I will immediately notify CHIP or its Administrator of the existence of this other coverage or my new address. I understand that any plan coverage that may be issued to me as a result of this application will terminate on the date that: (a) I am no longer a resident of Illinois; (b) I become eligible for Medicare; (c) I become eligible for medical assistance from the Illinois Department of Public Aid; or (d) I otherwise become ineligible for CHIP. I understand that my plan coverage can be rescinded as of the original issue date if it is later determined that any of the information on or supplemental to this application is false or inaccurate. I authorize any insurance issuer, insurance service or organization, group health plan, administrator, provider, institution or person that has my records or knowledge of my health history to give such information to CHIP or its designated representative or business associate. A copy of this authorization will be as valid as the original. Signature of Applicant Date Signature of Custodial Parent If the Applicant is Under 18 or Legal Guardian of the Person if the Applicant is Legally Incompetent HAVE YOU? Signed and dated the application? Yes No Answered ALL questions completely? Yes No Attached all documents as required (Questions 5, 9, 12, 18, 20)? Yes No YOU WILL NOT BE ABLE TO ENROLL IN CHIP OR HAVE ANY COVERAGE UNDER THIS STATE PROGRAM UNTIL WE HAVE BEEN ABLE TO DETERMINE THAT YOU HAVE MET ALL OF THE ELIGIBILITY REQUIREMENTS, YOUR APPLICATION AND ANY SUBSEQUENT APPLICATION UPDATES HAVE BEEN FINALLY APPROVED, AND GUARANTEED PAYMENT FOR YOUR FULL INITIAL PREMIUM HAS BEEN RECEIVED AND HONORED. PRODUCER: COMPLETE SECTION BELOW IF APPLICATION HAS BEEN MADE WITH YOUR ASSISTANCE. (Note: There is no contractual relationship established by your assisting in completing this application. You do not represent either CHIP or its Administrator, neither of which has responsibility for your action. You must be a licensed Illinois insurance producer and unrelated to the applicant to qualify for a referral fee. Producers who reside with the applicant are also ineligible for the referral fee.) PLEASE PRINT. Name Telephone (First) (Middle) (Last) (Area Code) (Phone Number) Name of Agency Street Address City ST Zip Code FEIN Number (Signature) Social Security No. -5-