In order to be considered Guarantee Issue (GI) it is assumed that all requirements listed throughout bulletproof have been met.

Notes In order to be considered Guarantee Issue (GI) it is assumed that all requirements listed throughout bulletproof have been met. Guarantee Issue makes group insurance available to California businesses employing between 1-50 full-time eligible employees for at least 50% of the previous calendar quarter. However, carriers do apply the timeframe differently. Each carrier requires a Quarterly Contribution Return & Report of Wages (Continuation) (DE-9C). Due to the length of time in business not all companies may have access to a DE-9C; therefore, details are provided as to which carrier will accept payroll in lieu of a DE-9C. When all employees are not listed on the DE-9C each carrier may require additional legal documentation. Please reference the appropriate business structure section within bulletproof for specific requirements. It should be noted that the documentation requirements listed in the Legal Doc Guidelines sections list the carrier s preferred document first. Documents listed thereafter will only be accepted when the first document is unavailable. Notes regarding coverage eligibility for Owner Only Groups (all business structures): o Aetna, CaliforniaChoice: These carriers will only allow owner only groups if there is at least 1 NON- SPOUSE / NON-OWNER w2 employee enrolling in Medical. o Anthem Blue Cross: This carrier will only allow owner only groups if there is at least 1 NON-SPOUSE / NON-OWNER w2 eligible employee (or an owner qualifying as a common law employee). o Blue Shield, Health Net, UnitedHealthcare: These carriers will only allow owner only groups if there is at least 1 NON-SPOUSE / NON-OWNER w2 eligible employee. Quarterly Minimum Wage Effective July 1, 2014 Effective July 1, 2015 Effective March 1, 2015 Effective May 1, 2015 CALIFORNIA SAN JOSE OAKLAND SAN FRANCISCO Hourly = $9.00 Hourly = $10.30 Hourly = $12.25 Hourly = $12.25 20 hrs/wk = $2340 20 hrs/wk = $2678 20 hrs/wk = $3185 20 hrs/wk = $3185 30 hrs/wk = $3510 30 hrs/wk = $4017 30 hrs/wk = $4777 30 hrs/wk = $4777 If part-time employees are not covered and DE-9C quarterly wages are greater than or equal to the amounts listed above then: HOURLY: provide 30 days of payroll showing wages, withholdings and hours worked. SALARY: provide 30 days of payroll showing salary, withholdings and a letter from the group stating which employees are part-time salaried and if they work less than 20 or 30 hours (whichever is indicated on the group application). beerepurves.com 1350 treat blvd. suite 470 walnut creek ca 94597 888.722.3373 888.978.7837 f license #0005851 102615

Guarantee Issue Aetna (1-50 enrolled) Guarantee Issue Guidelines (1-50 enrolled) The group must have been actively in business and employed a minimum of one (1) but not more than 50 eligible employees for a minimum of six (6) continuous weeks prior to the requested effective date. At least 51% of all employees must reside in California. At least one (1) eligible NON-SPOUSE / NON-OWNER W2 employee must enroll in Medical. The group must have and must maintain the business licenses and/or appropriate state filings allowing the company to conduct business in the state of California. Groups are not Guarantee Issue if they terminated health coverage with Aetna within the past 12 months. GI TIMETABLE JANUARY FEBRUARY MARCH Aetna (1-50) 11/15 12/15 1/15 APRIL MAY JUNE Aetna (1-50) 2/15 3/15 4/15 JULY AUGUST SEPTEMBER Aetna (1-50) 5/15 6/15 7/15 OCTOBER NOVEMBER DECEMBER Aetna (1-50) 8/15 9/15 10/15 Anthem Blue Cross (1-50 enrolled) Guarantee Issue Guidelines (1-50 enrolled) The group must have been actively in business and employed a minimum of one (1) but not more than 50 eligible employees for a minimum of 50% of previous calendar quarter or 50% of the prior calendar year.** **Start-up groups that meet all other eligibility requirements and provide 30 days of payroll within 45 days of the effective date will be accepted as Guarantee Issue immediately. At least 51% of all employees must reside in California. At least one (1) eligible NON-SPOUSE / NON-OWNER (or an owner qualifying as a common law employee) must be eligible to enroll in Medical. The group must have and must maintain the business licenses and/or appropriate state filings allowing the company to conduct business in the state of California. GI TIMETABLE JANUARY FEBRUARY MARCH Anthem (1-50) 11/15 11/15 11/15 APRIL MAY JUNE Anthem (1-50) 2/15 2/15 2/15 JULY AUGUST SEPTEMBER Anthem (1-50) 5/15 5/15 5/15 OCTOBER NOVEMBER DECEMBER Anthem (1-50) 8/15 8/15 8/15 beerepurves.com 1350 treat blvd. suite 470 walnut creek ca 94597 888.722.3373 888.978.7837 f license #0005851 102615

Guarantee Issue Blue Shield (1-50 enrolled) Guarantee Issue Guidelines (1-50 enrolled) The group must have been actively in business and employed a minimum of one (1) but not more than 50 eligible employees for a minimum of 50% of previous calendar quarter or 50% of the prior calendar year.** At least 51% of all employees must reside in California. At least one (1) eligible NON-SPOUSE / NON-OWNER (or an owner qualifying as a common law employee) W2 employee must enroll in Medical. The group must have and must maintain the business licenses and/or appropriate state filings allowing the company to conduct business in the state of California. GI TIMETABLE JANUARY FEBRUARY MARCH Blue Shield (1-50) 11/15 11/15 11/15 APRIL MAY JUNE Blue Shield (1-50) 2/15 2/15 2/15 JULY AUGUST SEPTEMBER Blue Shield (1-50) 5/15 5/15 5/15 OCTOBER NOVEMBER DECEMBER Blue Shield (1-50) 8/15 8/15 8/15 CaliforniaChoice (1-4 enrolled) Guarantee Issue Guidelines (1-4 enrolled) The group must have been actively in business and employed a minimum of one (1) but not more than 50 eligible employees for a minimum of six (6) continuous weeks prior to the requested effective date. At least 51% of all employees must reside in California. At least one (1) eligible NON-SPOUSE / NON-OWNER W2 employee must enroll in Medical. The group must have and must maintain the business licenses and/or appropriate state filings allowing the company to conduct business in the state of California. GI TIMETABLE JANUARY FEBRUARY MARCH CaliforniaChoice (1-4) 11/15 12/15 1/15 APRIL MAY JUNE CaliforniaChoice (1-4) 2/15 3/15 4/15 JULY AUGUST SEPTEMBER CaliforniaChoice (1-4) 5/15 6/15 7/15 OCTOBER NOVEMBER DECEMBER CaliforniaChoice (1-4) 8/15 9/15 10/15 CaliforniaChoice (5-50 enrolled) Guarantee Issue Guidelines (5-50 enrolled) All groups with at least five (5) medically enrolling employees are eligible as long as the business can provide at least one (1) week of payroll prior to the requested effective date. Payroll ledger from business start date to current should include the following items: (a) employee names; (b) employee wages; (c) employee wage withholdings; (d) wage summary totals; and (e) run date. If less than one (1) month of payroll is available, the balance for the month is due within 30 days of the requested effective date. GI TIMETABLE CaliforniaChoice (5-50) JANUARY - DECEMBER 0ne week of payroll beerepurves.com 1350 treat blvd. suite 470 walnut creek ca 94597 888.722.3373 888.978.7837 f license #0005851 102615

Guarantee Issue Health Net (1-5 enrolled) Guarantee Issue Guidelines (1-5 enrolled) The group must have been actively in business and employed a minimum of one (1) eligible employee for 50% of the previous calendar quarter or 50% of the prior calendar year. GI TIMETABLE JANUARY FEBRUARY MARCH Health Net (1-5) 11/15 11/15 11/15 APRIL MAY JUNE Health Net (1-5) 2/15 2/15 2/15 JULY AUGUST SEPTEMBER Health Net (1-5) 5/15 5/15 5/15 OCTOBER NOVEMBER DECEMBER Health Net (1-5) 8/15 8/15 8/15 Health Net (6-50 enrolled) Guarantee Issue Guidelines (6-50 enrolled) The group must have been actively in business and employed a minimum of six (6) eligible employees for a minimum of six (6) continuous weeks. GI TIMETABLE JANUARY FEBRUARY MARCH Health Net (6-50) 11/15 12/15 1/15 APRIL MAY JUNE Health Net (6-50) 2/15 3/15 4/15 JULY AUGUST SEPTEMBER Health Net (6-50) 5/15 6/15 7/15 OCTOBER NOVEMBER DECEMBER Health Net (6-50) 8/15 9/15 10/15 UnitedHealthcare (1-50 enrolled) Guarantee Issue Guidelines (1-50 enrolled) The group must have been actively in business and employed a minimum of one (1) eligible employees for 50% of the previous calendar quarter. GI TIMETABLE JANUARY FEBRUARY MARCH UHC (1-50) 11/15 11/15 11/15 APRIL MAY JUNE UHC (1-50) 2/15 2/15 2/15 JULY AUGUST SEPTEMBER UHC (1-50) 5/15 5/15 5/15 OCTOBER NOVEMBER DECEMBER UHC (1-50) 8/15 8/15 8/15 beerepurves.com 1350 treat blvd. suite 470 walnut creek ca 94597 888.722.3373 888.978.7837 f license #0005851 102615

Unique Groups CARVE-OUTS Aetna Location; Management vs. Non-Management; and Salary vs. Hourly Aetna will not consider carve-outs of these types. ELIGIBLE PLANS: GUARANTEE ISSUE (GI): DOCUMENTATION: Union vs. Non-Union All Yes, when all conditions listed below have been met. Total group size (union and non-union) must be 50 or less AND 5-50 eligibles must be enrolled and maintained within Aetna's California Network Service Area AND 75% of the carve-out population must enroll with Aetna. Group must prove that Union employees are covered by the Union plan, i.e. copy of healthcare billing statement for previous month. Anthem Blue Cross Location; Management vs. Non-Management; and Salary vs. Hourly Anthem Blue Cross will not consider carve-outs of these types. ELIGIBLE PLANS: GUARANTEE ISSUE (GI): DOCUMENTATION: Union vs. Non-Union All Yes, when all conditions listed below have been met. Total group size (union and non-union) must be 50 or less AND 1-50 eligibles must be enrolled and maintained within Anthem Blue Cross AND 1-14 eligibles: 70% of the carve-out population must enroll with Anthem Blue Cross OR 15-50 eligibles: 50% of the carve-out population must enroll with Anthem Blue Cross. Union roster is required for identifying Union members AND Declinations are not required for Union employees waiving coverage (considered a valid waiver). Blue Shield Location; Management vs. Non-Management; and Salary vs. Hourly Blue Shield will not consider carve-outs of these types. ELIGIBLE PORTFOLIOS: GUARANTEE ISSUE: DOCUMENTATION: Union vs. Non-Union All Yes, when all conditions listed below have been met. Total group size (union and non-union), must be 50 or less AND 5-50 eligibles must be enrolled and maintained with Blue Shield AND 1-5 eligibles: 65% of the carve-out population must enroll with Blue Shield OR 5-50 eligibles: 25% of the carve-out population must enroll with Blue Shield. Since union members are considered valid waivers, Blue Shield will write owners only for a non-union carve-out. A copy of the collective bargaining agreement showing that the employer pays contributions to the trust fund AND The statement of ERISA Rights form and the union trust fund Summary Plan Description. www.beerepurves.com 1350 treat blvd. suite 470 walnut creek ca 94597 888.722.3373 888.978.7837 f license #0005851 102215

Unique Groups CARVE-OUTS CaliforniaChoice Location; Management vs. Non-Management; and Salary vs. Hourly CaliforniaChoice will not consider carve-outs of these types. ELIGIBLE PLANS: GUARANTEE ISSUE (GI): DOCUMENTATION: Union vs. Non-Union All Yes, when all conditions listed below have been met. Total group size (union and non-union) must be 50 or less AND 70% of the carve-out population must enroll with CaliforniaChoice. Union employees must be marked U on the DE-9C. A Union billing statement must be reconciled against the DE-9C. A Union card must be provided for Union employees not listed on the Union billing statement. Health Net Location; Management vs. Non-Management; and Salary vs. Hourly Health Net will not consider carve-outs of these types. ELIGIBLE PORTFOLIOS: GUARANTEE ISSUE: DOCUMENTATION: Union vs. Non-Union All Yes, when all conditions listed below have been met. Total group size (union and non-union) must be 50 or less AND 1-50 eligibles must be enrolled and maintained with Health Net AND 1-5 eligibles 75% of the carve-out population must enroll with Health Net OR 6-50 eligibles 50% of the carve-out population must enroll with Health Net. Union roster identifying union employees AND Collective Bargaining Agreement must be provided. Declinations are not required for union employees waiving coverage (considered a valid waiver). UnitedHealthcare Location; Management vs. Non-Management; and Salary vs. Hourly UnitedHealthcare will not consider carve-outs of these types. ELIGIBLE PLANS: GUARANTEE ISSUE: DOCUMENTATION: Union vs. Non-Union All Yes, when all conditions listed below have been met. Total group size (union and non-union) must be between 5-50 AND All included classes must meet participation guidelines for the class AND Minimum of 5 enrolled employees required Copy of the Union bill Letter from the group representative or broker, on employer letterhead, including: (a) class description of the carve-out population; (b) union employees must have medical coverage through their union www.beerepurves.com 1350 treat blvd. suite 470 walnut creek ca 94597 888.722.3373 888.978.7837 f license #0005851 102215

Unique Groups CONSOLIDATION OF COMPANIES Aetna To determine eligibility, the following conditions must be met: One owner must have controlling interest of all businesses needing to be consolidated OR Owner must file, or is eligible to file, an Affiliation Schedule (Form #851) allowing for a combines tax return for all companies needing to be consolidated AND Complete and submit the Common Ownership Form AND Eligible employees must total 50 or less. Anthem Blue Cross To determine eligibility, the following conditions must be met: Letter from the company s tax advisor (e.g. CPA, Attorney, Controller) certifying that all companies are affiliated and eligible to file consolidated tax returns for State taxation AND Eligible employees must total 50 or less. Blue Shield To determine eligibility, the following conditions must be met: Copies of the Statement of Information or Articles of Incorporation reflecting all officers and owners OR Copies of all Partnership Agreements listing all partners names AND The employer s CPA must provide a letter stating all business entities are eligible to file a combined tax return AND Eligible employees must total 50 or less. CaliforniaChoice To determine eligibility, the following conditions must be met: Each company must share a minimum of 50% common ownership AND Each company must have a related industry AND Each company must have at least 1 medically enrolled common-law employee who is not an owner or spouse of the owner AND Each company's home office must be located in California with a minimum of 51% of eligible employees residing in California AND Total number of eligibles, for all combined groups, may not exceed 50 employees. Required Documentation: Employer must complete the Common Ownership Statement AND If less than 5 eligible employees enroll, proof of common ownership is required if the owner is not listed on the DE-9C. Health Net To determine eligibility, the following conditions must be met: Letter from a CPA certifying that all companies are affiliated and eligible to file consolidated tax returns for State taxation AND Eligible employees must total 50 or less. UnitedHealthcare To determine eligibility, the following conditions must be met: Copies of the Statement of Information reflecting all officers and owners OR Copies of all Partnership Agreements listing all partners names AND The employer s CPA must provide a letter stating all business entities are eligible to file a combined tax return AND Eligible employees must total 50 or less. www.beerepurves.com 1350 treat blvd. suite 470 walnut creek ca 94597 888.722.3373 888.978.7837 f license #0005851 102215

Unique Groups PEO Aetna Exiting a PEO Any group leaving Aetna s PEO must complete the PEO Questionnaire AND Employer must have payroll established under their company name, not the PEO. Remaining in a PEO Aetna will not consider PEOs of this type. Anthem Blue Cross Exiting a PEO Group must provide a copy of the PEO chargeback invoice that has been billed to the group address. It must include names of each previously leased employee AND Completed and signed Conditions of Enrollment form AND Within 45 days of approval, the group is required to provide 30 days of complete companywide payroll. Remaining in a PEO Anthem will not consider PEOs of this type. Blue Shield Exiting a PEO If any employee of the group had Blue Shield of California coverage through the PEO, the group will not be eligible for coverage from Blue Shield for 12 months following the disenrollment date from the plan contract that existed through the PEO AND A copy of the letter sent from the PEO to the client business verifying the cancellation of the leasing arrangement will be required AND If a copy of a payroll register from the PEO is submitted with the new group application, separating the formerly leased employees by business location, the group will be considered a qualified group. Remaining in a PEO Blue Shield will not consider PEOs of this type. CaliforniaChoice Exiting a PEO An employer letter describing the PEO spin-off scenario including the group s official split off date AND A minimum of one week payroll from the new company is required for approval and the balance for the month due within 30 days of the effective date. Remaining in a PEO Use verbiage from CaliforniaChoice s PEO sub-group Letter to create an employer letter AND The Statement of Compliance portion of the Employer Application must be signed by an authorized representative of the sub-group, not a PEO representative AND In lieu of a DE-9C, the group must submit a payroll ledger for the most current 3 months including group company name, employee names, SS#s, wages, withholdings, and payroll salary information AND The most recent PEO invoice matching payroll salary information AND Home office must be located in California AND Address provided on the Employer Application must be the group s physical location AND COBRA provisions must be based on the group s group size, not the PEO s group size AND FMLA provisions apply to a sub-group when the PEO is providing staffing services and when compliance is determined by the PEO. www.beerepurves.com 1350 treat blvd. suite 470 walnut creek ca 94597 888.722.3373 888.978.7837 f license #0005851 102215

Unique Groups PEO Health Net Exiting a PEO Group must submit the quarterly wage report prepared by the PEO. If the PEO does not prepare a quarterly wage report for each employer, payroll (chargeback invoice) from the PEO may be submitted. o 6+ enrolling: at least 6 weeks of payroll (chargeback invoices) required. o Less than 6 enrolling: payroll for 50% of the previous calendar quarter required. Remaining in a PEO See Exiting a PEO for information. UnitedHealthcare Exiting a PEO Approval is contingent upon UnitedHealthcare receiving, within 45 days of the effective date, 30 days of payroll records for all employees; and UnitedHealthcare reserves the right to rescind or non-renew coverage if payroll documentation is not provided in a timely manner, or does not meet UnitedHealthcare s criteria for enrollment eligibility AND Will be considered for small group coverage with a coverage date on or after the termination date of the PEO arrangement AND The employer group must meet the definition of an AP 1672/1083 employer and must have maintained 1-50 employees for 50% of the previous calendar quarter or 50% of the previous calendar year to be considered guaranteed issue AND The employer group must have offered the employees health insurance previously through the PEO AND A copy of the contract termination letter sent from the PEO to the client (employer) business. This letter is generated by the PEO and verifies the cancellation of the leasing arrangement as well as the cancellation date AND A letter from the company owner/officer stating the following that the company has cancelled its contract with the PEO and the effective date of cancellation AND Prior carrier bill from the PEO with the employee census confirming prior coverage AND 6 weeks of chargeback invoices from the PEO to establish AB 1672/1083 AND PEO Benefit Register or prior carrier bill so preexisting will not be applied. Remaining in a PEO Contract must be entered into only with the client company (the employer group) of the PEO that meets the definition of a small employer AND Only an officer of the client company may enter into, and sign, the insurance contract; it cannot be signed by the PEO and/or PEO co-employer AND UnitedHealthcare must be the sole provider of health insurance AND If the employer group currently has UnitedHealthcare health coverage offered or sponsored through a PEO that is covered as an active UnitedHealthcare mid-market group (ADP or Administaff, for example), they will not be considered eligible for coverage as a separate small employer unless they terminate their PEO relationship AND Payroll report must be provided from a legitimate payroll record service, issued in the name and tax ID number of the individual employer group, and may not contain employees of any other PEO client company. o A small group employer that utilizes the services of the PEO for payroll purposes alone and the PEO otherwise does not act as a co-employer, UnitedHealthcare will offer coverage to the small group client company without requiring the employer to terminate their PEO contract. www.beerepurves.com 1350 treat blvd. suite 470 walnut creek ca 94597 888.722.3373 888.978.7837 f license #0005851 102215

Unique Groups SPIN-OFF Aetna Group must be a current Aetna group customer AND A letter from the group or broker indicating the group is enrolling as a spin off. Letter needs to include the name of the group they are spinning off from AND Ownership documents showing that the company is a newly formed separate entity AND A minimum of 2 weeks payroll. If the group that is spinning off has been in business longer than 2 weeks, payroll will be required for amount of time in business to a maximum of 6 consecutive weeks. Anthem Blue Cross A spin-off is treated as a start-up AND A minimum of six (6) weeks payroll is required. CaliforniaChoice The first available effective date is the first of the month, on or following the group s official split-off date. Employees from the original company can maintain their original date of hire for the purposes of satisfying any waiting periods applied by the Employer. Documentation Requirements: Letter from Employer, on company letterhead, describing the split-off scenario, including the official split-off date AND Payroll ledger (from business start date to current under the new company structure) should include: (a) company name; (b) employee names; (c) employee wages; (d) employee wage withholdings; (e) wage summary totals; (f) run date. If less than one month of payroll is available, the balance for the month is due within 30 days of the effective date. Groups with less than 5 enrolling must have at least 1 eligible employee with 6 weeks of payroll. Owner Eligibility requirements for each enrolling owner/partner (not listed on the payroll with at least a minimum wage salary): If less than 5 medically enrolled, legal documents could be required by underwriting. Health Net Prior carrier bill or ID cards for all employees (from the previous employer) AND Minimum of 2 weeks of payroll is required; groups with more than 2 weeks of payroll are required to submit the available payroll with a maximum of 6 weeks AND Ownership documents showing that the company is a newly formed, separate entity AND Letter from the group or broker, on company letterhead, indicating the group is enrolling as a spin-off. If the group did not have coverage under the previous business entity, or if the majority of those enrolling were not employed by or did not have coverage through the previous business entity, the group will not be considered for coverage. Blue Shield At least 50% of the employees in the spin-off group must have been enrolled in Blue Shield through the former business AND The new group does not have shared ownership with the business they have separated from AND All enrollment documents are required (master application, subscriber applications, refusals, business check, etc.) AND Ownership paperwork and eligibility verification for the owner is required AND A copy of the most recent payroll register is required. If no payroll register is available, a W-4 form for all employees will be initially required, with subsequent submission of the first complete payroll register required within 30 days of the group s effective date. UnitedHealthcare The group must be spinning off from a company whose medical coverage resides with UnitedHealthcare AND Despite being a newly formed business, they are not subject to 50% of the previous calendar quarter/year rule AND A letter from the employer, on company letterhead, stating their request to spinoff and their requested effective date AND Standard group submission and underwriting rules apply. Groups spinning off from a company whose medical coverage resides with a carrier other than UnitedHealthcare: Standard group submission and underwriting rules apply AND A letter from the employer, on company letterhead, stating their request to spinoff and their requested effective date. www.beerepurves.com 1350 treat blvd. suite 470 walnut creek ca 94597 888.722.3373 888.978.7837 f license #0005851 102215

Legal Doc Guidelines SOLE PROPRIETOR A Sole Proprietor is determined by the Social Security Number (SSN) on the Schedule C; always considered a single owner. Aetna IRS Form 1040 C or 1040 F or Current Schedule C OR IRS Form 1040 SE OR IRS Form 1040 ES (estimated tax) OR State Business License OR Fictitious Business Name Filing acceptable if group has not yet filed a Schedule C. Anthem Blue Cross Current Schedule C must be submitted unless not available due to the length of time in business OR California Business License OR Fictitious Business Name Filing. Blue Shield In business < 1 year California Business License OR Fictitious Business Name Filing When less than six (6) enrolling, group must show proof of compensation (draw checks). In business > 1 year Current Schedule C must be submitted unless not available due to the length of time in business. CaliforniaChoice (if less than 5 medically enrolling) Schedule C (for preceding calendar year) OR Current California Business License and a copy last 2 cancelled draw checks (front and back) OR Fictitious Business Name Filing dated prior to requested effective date and a copy of last 2 cancelled draw checks (front and back). Health Net Current Schedule C OR Fictitious Business Name Filing OR California Business License. UnitedHealthcare In business < 1 year < 6 enrolling or family only groups: California Business License listing the owner s name 6+ enrolling: DE-9C In business > 1 year < 6 enrolling or family only groups: IRS Schedule C (Form 1040) 6+ enrolling : DE-9C Note: Groups comprised only of family members must provide separate tax documentation. A DE-9C may also be required with current legal and/or tax documents if ownership is in question. beerepurves.com 1350 treat blvd. suite 470 walnut creek ca 94597 888.722.3373 888.978.7837 f license #0005851 101615

Legal Doc Guidelines CORPORATIONS Corporations established out-of-state also require a Certificate of Qualification or Statement by Foreign Corporation. Aetna IRS Form 1120 or 1120 W (C-Corp & Personal Service Corp) OR IRS Form 1120 S Schedule K-1 or 1040 ES (S-Corp) OR Fictitious Business Name Statement OR Articles of Incorporation or Statement by Domestic Stock including name of officers, shareholders and directors. Anthem Blue Cross Statement of Information (substitutes include a current C-Corp Form 1120, S-Corp Schedule K-1 or 1120S, listing the names of all officers) OR Statement by Domestic Stock OR Articles of Incorporation filed and stamped listing names of all officers. Blue Shield In business < 1 year: Articles of Incorporation filed and stamped listing names of all officers OR Statement of Information, listing owners/offices with State Endorsement stamp AND When less than six (6) enrolling, group must show proof of compensation (draw checks). In business > 1 year: IRS Schedule K-1 (Form 1120s) for all enrolling Owners/Officers OR W-2. CaliforniaChoice (required if less than 5 medically enrolling) Statement of Information listing owners/partners with State Endorsement stamp prior to requested effective date OR Schedule E for preceding calendar year to include owners/partners name OR Articles of Incorporation with State Endorsement dated prior to requested effective date AND owners/partners last 2 cancelled draw checks (front and back). Health Net IRS Form 1120 listing all owners and percentage of stock owned OR Articles of Incorporation filed and stamped listing names of all officers OR Statement by Domestic Stock Corporation / Statement of Information (an unstamped document may be accepted with a printout from the California Business Portal if at least one officer listed is also listed on the printout as the Agent for Service of Process. The signature date must also be consistent with the filing date. Otherwise, the document must be stamped or contain a pre-printed file number from the State.) AND Statement of Designation by Foreign Corporation. UnitedHealthcare S-Corps and C-Corps In business <1 year: < 6 enrolling or family only groups: o Articles of Incorporation filed and stamped listing names of all officers OR o Statement of Information filed and stamped listing names of all officers. 6+ enrolling: DE-9C In business > 1 year (S-Corps): IRS Schedule K-1 (Form 1120s) for all enrolling Owners/Officers In business > 1 year (C-Corps): IRS Form 1125E (pages 1 & 2) which includes Schedule E Note: Groups comprised only of family members must provide separate tax documentation. A DE-9C may also be required with current legal and/or tax documents if ownership is in question. beerepurves.com 1350 treat blvd. suite 470 walnut creek ca 94597 888.722.3373 888.978.7837 f license #0005851 101615

Legal Doc Guidelines PARTNERSHIPS Aetna Latest filed Schedule K-1 (1065 Partner's Return) OR Latest filed IRS Form 1040 C or 1040 F OR Latest filed IRS Form 1040 ES (estimated tax) OR Partnership Agreement acceptable if group has not been in business long enough to have filed a Schedule K-1 OR Fictitious Business Name Statement OR Business License. Anthem Blue Cross Current Schedule K 1 (1065 Partner's Return) OR Partnership Agreement and Federal Tax ID Appointment Letter. Blue Shield In business < 1 year Partnership Agreement filed and stamped and signed by all partners OR Business license OR DBA filing When less than six (6) enrolling, group must show proof of compensation (draw checks). In business > 1 year: IRS Schedule K-1 (Form 1065) for each enrolling partner OR Tax extensions are not permitted CaliforniaChoice (if less than 5 medically enrolling) Legal Notarized Partnership Agreement dated and notarized prior to the requested effective date OR Schedule K-1 (1065 Partner's Return) for preceding calendar year. Health Net Current Schedule K-1 (1065 Partner's Return) OR Statement of Partnership Authority OR Partnership Agreement; deemed acceptable per underwriter s discretion OR Fictitious Business Name Statement listing both names OR Tax Certificate listing both names. UnitedHealthcare In business < 1 year < 6 enrolling or family only groups: Partnership Agreement filed and stamped and signed by all partners 6+ enrolling: DE-9C In business > 1 year: IRS Schedule K-1 (Form 1065) for each enrolling partner OR Partnership Agreement signed by all partners Note: Groups comprised only of family members must provide separate tax documentation. A DE-9C may also be required with current legal and/or tax documents if ownership is in question. beerepurves.com 1350 treat blvd. suite 470 walnut creek ca 94597 888.722.3373 888.978.7837 f license #0005851 101615

Legal Doc Guidelines LIMITED PARTNERSHIP (LP) LPs established out-of-state also requires a Foreign Limited Partnership Application for Registration (form # LP-5) filed and stamped by the Secretary of State. Aetna Latest filed Schedule K-1 (1065 Partner's Return) OR Partnership Agreement acceptable if group has not been in business long enough to have filed a Schedule K-1. Anthem Blue Cross Current Schedule K 1 (1065 Partner's Return) OR Partnership Agreement and Federal Tax ID Appointment Letter. NOTE: Limited Partners of a Limited Partnership are ineligible unless they appear on the DE-9C. Blue Shield In business < 1 year Partnership Agreement filed and stamped and signed by all partners OR Business license OR DBA filing When less than six (6) enrolling, group must show proof of compensation (draw checks). In business > 1 year: IRS Schedule K-1 (Form 1065) for each enrolling partner OR Tax extensions are not permitted CaliforniaChoice (if less than 5 medically enrolling) Legal Notarized Partnership Agreement dated and notarized prior to the requested effective date OR Schedule K-1 (1065 Partner's Return) for preceding calendar year. Health Net Schedule K-1 (1065 Partner's Return) OR Certificate of Limited Partnership OR Partnership Agreement; deemed acceptable per underwriter s discretion OR Fictitious Business Name Statement showing both names OR Tax Certificate showing both names AND Foreign LP Application of Registration. UnitedHealthcare Limited Partnerships are not underwritten by UnitedHealthcare. beerepurves.com 1350 treat blvd. suite 470 walnut creek ca 94597 888.722.3373 888.978.7837 f license #0005851 101615

Legal Doc Guidelines LIMITED LIABILITY PARTNERSHIP (LLP) LLPs established out-of-state also requires a Registered LLP Certificate of Registration (Form #LLP-1) filed and stamped by the Secretary of State. Aetna Latest filed Schedule K-1 (1065 Partner's Return) OR Latest filed IRS Form 1040 C or 1040 SE OR Latest filed IRS Form 1040 ES (estimated tax) OR Partnership Agreement acceptable if group has not been in business long enough to have filed a Schedule K-1 OR Fictitious Business Name Statement OR Certificate of Organization OR Business License. Anthem Blue Cross Current Schedule K 1 (1065 Partner's Return) OR Partnership Agreement and Federal Tax ID Appointment Letter. Blue Shield In business < 1 year Partnership Agreement filed and stamped and signed by all partners OR Business license OR DBA filing When less than six (6) enrolling, group must show proof of compensation (draw checks). In business > 1 year: IRS Schedule K-1 (Form 1065) for each enrolling partner OR Tax extensions are not permitted CaliforniaChoice (if less than 5 medically enrolling) Legal Notarized Partnership Agreement dated and notarized prior to the requested effective date OR Schedule K-1 (1065 Partner's Return) for preceding calendar year. Health Net Schedule K-1 (1065 Partner's Return) OR Registered Limited Liability Partnership Registration OR Partnership Agreement; deemed acceptable per underwriter s discretion OR Fictitious Business Name Statement showing both names OR Tax Certificate showing both names AND LLP Certificate of Registration. UnitedHealthcare In business < 1 year < 6 enrolling or family only groups: Partnership Agreement filed and stamped and signed by all partners 6+ enrolling: DE-9C In business >1 year: IRS Schedule K-1 (Form 1065) for each enrolling partner OR Partnership Agreement signed by all partners Note: Groups comprised only of family members must provide separate tax documentation. A DE-9C may also be required with current legal and/or tax documents if ownership is in question. beerepurves.com 1350 treat blvd. suite 470 walnut creek ca 94597 888.722.3373 888.978.7837 f license #0005851 101615

Legal Doc Guidelines LIMITED LIABILITY CORPORATION (LLC) LLCs established out-of-state also require a LLC Application of Registration (Form #LLC-5) filed and stamped by the Sec. of State. Aetna IRS Form 1120 OR 1120 A or 1120 W OR IRS Form 1120 S Schedule K-1 OR 1040 ES OR IRS Form 8832 (Entity Classification treated as a corporation) OR Fictitious Business Name Statement OR Articles of Organization (with Operating Agreement) OR Statement by Domestic Stock OR Statement of Information stamped and filed by state of California prior to the date. Anthem Blue Cross Current Schedule K 1 (1065 Partner's Return) OR Articles of Organization (with Operating Agrmt) stamped and filed by state of California prior to date required for GI OR Statement of Information stamped and filed by state of California prior to the date required for GI. Blue Shield In business < 1 year Articles of Organization (with Operating Agrmt) stamped and filed by state of California prior to date required for GI OR Statement of Information stamped and filed by state of California prior to the date required for GI. < 6 enrolling: groups must show proof of compensation (draw checks) In business > 1 year Current Schedule K 1 (1065 Partner's Return) OR Schedule C OR Schedule F CaliforniaChoice (if less than 5 medically enrolling) Schedule K-1 (1065 Partner's Return) OR LLC Statement of Info listing owners/partners with State Endorsement stamp prior to requested effective date OR LLC Form 568 Tax Filing for preceding calendar year OR Articles of Organization with State Endorsement stamp prior to requested effective date AND Owners/partners last 2 cancelled draw checks (front and back). Health Net Schedule K-1 (1065 Partner's Return) OR IRS Form 1120 listing all owners and percentage of stock owned OR Articles of Organization (with Operating Agrmt) stamped and filed by state of California prior to date required for GI OR Statement of Information (an unstamped document may be accepted with a printout from the California Business Portal if at least one officer listed is also listed on the printout as the Agent for Service of Process. The signature date must also be consistent with the filing date. Otherwise, the document must be stamped or contain a pre-printed file number from the State.) AND LLC Application of Registration. UnitedHealthcare In business < 1 year < 6 enrolling or family only groups: LLC Operating Agreement signed by all managers/members/parties 6+ enrolling: DE-9C In business > 1 year LLC Operating Agreement signed by all managers/members/parties OR Copies of appropriate tax returns (requirements based on how LLC was formed see Partnership or Sole Proprietorship) Note: Groups comprised only of family members must provide separate tax documentation. A DE-9C may also be required with current legal and/or tax documents if ownership is in question. beerepurves.com 1350 treat blvd. suite 470 walnut creek ca 94597 888.722.3373 888.978.7837 f license #0005851 101615

Legal Document Samples Schedule C (1040) Profit/Loss from Business Schedule K1 (1065) Partnership Income Schedule K1 (1120S) S Corp Tax Return Affiliations Schedule (851) Estimated Tax for Corporations (1120W) Schedule SE Self-Employment Tax Application for Employer ID Number (SS4) Articles of Incorporation of a Professional Corporation LLC Articles of Organization

Legal Document Samples Certificate of Qualification Certificate of Limited Partnership Statement of Information (Domestic Stock) Statement of Information (LLC) Statement of Information (Foreign Corp) Statement of Information (Non-Profit) Affiliation Schedule IRS 851 Certificate of Qualification Statement of Information (LLC) Schedule E Supplement Income & Loss Foreign LP Application for Registration Registered LLP Registration LLC Application for Registration

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