TRH HEALTH INSURANCE COPANY APPLICATION OR COVERAGE PLEASE PRINT USING BLACK INK Section 1 Primary Applicant Information OICE USE ONLY irst Name I Last Name Phone No. ( ) - ay we leave a message? Yes No ailing Address Alternate No. ( ) - ay we leave a message? Yes No Sub Group County City State Zip Code County of Residence Email Address (if applicable): Effective Date ale emale arital Status Single arried Date of arriage How did you hear about TRHH? Internet TV Radio ail Ad Billboard Phone Book TN arm Bureau amily/riend ID Number nt Are you an existing TN arm Bureau member? Section 2 BHP Gold G01CP Yes, I am an existing TN arm Bureau member. TN arm Bureau membership is in the name of: TN arm Bureau membership number: No, I am not an existing TN arm Bureau member. Individual - $1,000 deductible BHP Silver S01CP Individual - $2,500 deductible BHP Silver S01CPH (HSA-Qualified) Individual - $2,500 deductible I am submitting my TN arm Bureau embership Application and Agreement. I would like more information about becoming a TN arm Bureau member and understand TRHH will share my name and contact information with TN arm Bureau for marketing purposes and that no other information will be disclosed. Coverage Options amily - $2,000 deductible amily - $5,000 deductible amily - $5,000 deductible BHP Bronze B01CP Individual - $4,500 deductible BHP Bronze B01CPH (HSA-Qualified) Individual - $5,000 deductible amily - $9,000 deductible amily - $10,000 deductible BHP Catastrophic C01CP (Subscriber must be under age 30 or eligible due to a mandated affordability or hardship exception.) Individual - $6,850 deductible Section 3-A Dependents to be Covered Under This Policy SPOUSE irst Name I Last Name Gender DEPENDENT irst Name I Last Name Gender DEPENDENT irst Name I Last Name Gender DEPENDENT irst Name I Last Name Gender DEPENDENT irst Name I Last Name Gender Section 3-B amily - $13,700 deductible Yes No 1. On average, has any applicant used any tobacco products 4 or more times per week within the past 6 months? (Includes all tobacco products, except tobacco used for religious or ceremonial purposes.) Applicant name(s): Yes No 2. Is any applicant covered by edicare/edicaid? Applicant name(s): Yes No 3. Is every applicant a Legal Resident or a Citizen of the United States? Yes No 4. Is any applicant covered under any other individual or group health coverage or plan of benefits? Applicant name(s): Page 1 of 3
Primary Applicant irst Name I Last Section 3-C Please answer the following question if you are applying for any dependent other than your spouse: Yes No Are all children for whom you are applying under the age of 26, and your (Please select all that apply): Natural children Adopted children Step-children Children placed with you in anticipation of adoption Children for whom you are legal guardian? If No, please explain TRHH reserves the right to request proof of eligibility at any time. In the event eligibility cannot be determined based on the answers submitted on this application, additional information may be requested. Section 4 Special Enrollment Questions You must provide written proof of eligibility for any of the qualifying events marked in Section 4. You may be eligible for health insurance coverage under a Special Enrollment Period if at least one of the following qualifying events occurred in the last 60 days. ark all that apply, indicate to whom they apply, and answer the corresponding question(s). 1. Loss of health insurance. Which applicant(s)? a. Did the applicant lose health insurance due to failure to pay premium? Yes No If Yes, the applicant is not eligible for health insurance coverage under a Special Enrollment Period. If No, reason for loss of insurance: b. Initial effective date of insurance? (/DD/YY) / / c. Termination date of insurance? (/DD/YY) / / d. Type of coverage lost: Employer Group COBRA Short term Individual edicaid Other (please specify) e. Prior insurance company name: f. Prior insurance company phone number: g. Prior insured/member s name and ID number: 2. arriage. Which applicant(s)? a. When did the applicant get married? (/DD/YY) / / 3. Birth, adoption, guardianship or placement for adoption. Which applicant(s)? a. When was the applicant born, adopted, or placed for adoption? (/DD/YY) / / 4. ove to a different state. Which applicant(s)? a. When did the applicant move? (/DD/YY) / / b. What is the prior address? Street City State Zip 5. Gain citizenship or lawful presence in the United States. Which applicant(s)? a. When did the applicant gain citizenship or lawful presence in the United States? (/DD/YY) / / 6. ember of a federally recognized tribe or an Alaska Native Corporation Shareholder. Which applicant(s)? LG--L15-032 1/1/16 Page 2 of 3
Primary Applicant irst Name I Last Section 5 Acknowledgements Please Read Carefully and Sign the Appropriate Box Below TRHH is entitled to rely solely on the statements made on this application which are complete and correct. I understand that any coverage which may be issued: Will be effective, subject to all the terms and conditions of the policy, on the date indicated on the Schedule Declarations Page included with such policy; and Shall be binding only if each statement included on the application is complete and true. I understand the information in this application and any information obtained with this authorization will be used by TRHH to determine eligibility for coverage and that coverage and rates will be affected by this information. I declare that the foregoing statements provided by me in this application in its entirety are true, correct and complete for myself, my spouse and all children for whom I am applying. I understand it is a crime to knowingly provide false, incomplete or misleading information to TRHH for the purposes of defrauding the company. Penalties include imprisonment, fines, and denial of coverage. I understand that I do not have coverage with TRHH until my application has been approved, my initial premium payment has cleared my bank account and TRHH has issued a policy to me. I understand if TRHH rejects this application, under no circumstances will any benefits be payable. I understand I should not terminate existing coverage until I have accepted TRH Health Insurance Company coverage. By submitting this application, I agree that TRHH s grievance process will govern any dispute with the application or any policy issued. Acknowledgement for Individual Adult or amily Coverage Subscriber Signature Date Acknowledgement for Children Under 18 PLEASE COPLETE THE OLLOWING I YOU ARE APPLYING OR CHILD-ONLY COVERAGE. I declare that the foregoing statements provided by me in this application in its entirety are true, correct and complete for the child for whom I am applying. I understand that if coverage is issued, I am the only person allowed to sign for changes to or cancellation of this policy. Signature of Subscriber Parent Relationship Date Print Name of Subscriber Parent Social Security Number I declare that the foregoing statements provided by me in this application in its entirety are true, correct and complete for the child for whom I am applying. I understand that if coverage is issued, I cannot sign for changes to or cancellation of this policy. I understand as parent or legal guardian of the child, I may, depending upon the age of the child, have the right to obtain information about this child s application and policy if issued. Signature of Non-Subscriber Parent Relationship Date Print Name of Non-Subscriber Parent A scanned, imaged or photocopied version of this completely executed form will have the same force and effect as the original document. LG--L15-032 1/1/16 Page 3 of 3
INSTRUCTIONS OR ACA BANK DRAT AUTHORIZATION OR The following must be completed to authorize your automatic bank draft. If you are changing bank account information, this form must be received in our office ten (10) days prior to the next scheduled draft date. 1. Signature of Applicant/Subscriber (Required) and Signature of Applicant/Subscriber (Required) Subscriber must print name, sign and date that he/she agrees to the terms and conditions as set forth in the ACA Bank Draft Authorization orm. The ACA Bank Draft Authorization orm must be signed by parent or legal guardian if member is under age 18. 2. Print Payor Name (Required) and Signature of Payor (Required) Payor (owner/signatory of account) must print and sign name. 3. Date (Required) and County (Required) Applicant must date the form and write the arm Bureau County name. 4. Identification Number (Required, if existing contract) Subscriber s arm Bureau Health Plans identification number. 5. Check New Application or Bank Change box. If Bank Change please write in effective date of change. 6. Check Account Type Checking or Savings and complete financial bank information. 7. ail completed form to arm Bureau Health Plans, P.O. Box 313, Columbia, TN 38402-0313, or you may fax to (931) 560-4278, Attention: Billing Department. 8. Verify receipt of mailed or faxed form by calling (931) 560-0041 or toll free (877) 874-8323 and select the option for Billing Services. BL-15-113
BL-15-113 ACA BANK DRAT AUTHORIZATION OR I hereby authorize arm Bureau Health Plans to initiate debit entries from the account indicated below for the monthly premium payment. The depository named below is authorized to debit my account. I acknowledge I am authorized to sign this agreement on behalf of all covered individuals and signatories to the account. I further understand I have the right to revoke this authorization by notifying arm Bureau Health Plans in writing at least ten (10) days prior to the time payment is due. I further agree that should a debit be dishonored, whether with or without cause and whether intentionally or inadvertently, arm Bureau Health Plans shall have no liability whatsoever, even if such dishonor results in forfeiture of coverage. Print Applicant/Subscriber Name (Required) Print Payor Name (Required) Signature of Applicant/Subscriber (Required) (ust be signed by parent, step-parent or legal guardian of minor applicant) Signature of Payor (Required) Date County (Required) Subgroup ID Number (Required, if existing contract) New Application Bank Change (effective date) Account Type - Checking Savings PLEASE COPLETE (or attach voided check) Name and Address of inancial Institution (Required) Routing Number (Required) Account Number (Required) Cancellation- The Subscriber may cancel this coverage for any reason by giving ten (10) days written notice to arm Bureau Health Plans. Coverage will remain in effect until the paid-to date. Please see your policy for specific information regarding cancellations and cancellations due to death of Subscriber.