Colorado Employer Application For employer groups with 1-50 employees

Colorado Employer Application For employer groups with 1-50 employees P.O. Box 14326 Reading, PA 19612 www.seechangehealth.com Main: 866-340-7182 Fax: 610-374-6986 Enroll@SeeChangeHealth.com 1. Company Information Company Group. (For existing groups) Street Address City County State Zip Code Billing Address Same as Street Address City County State Zip Code Business Organization Corporation Partnership Sole Proprietorship LLC Other, please specify Standard Industrial Classification (SIC)Code Type of Business (Please be specific) Date Company Established / MM/YYYY Tax ID. Has Company been insured by SeeChange within the past 12 months? If yes, termination date of coverage Company Contact Contact Phone. Contact Fax. Contact Email Address 2. Company Contributions to Employee/Dependent Premiums The percentage your company will contribute toward employee and dependent premiums Employee % Dependent % (50% -100%) (0% - 100%) 3. Benefit Plan And Effective Date Please select your benefit plan and the desired effective date Available plan suites: Classic 2200 Deluxe 500 Co-Pay HSA 3000 Classic 3500 Classic 5000 Optional for groups of five or more enrolling employees Employee Option Program - You may select one plan suite or combine the HSA and one other plan suite *te: Employees may ONLY select within chosen plan suite(s) Requested Effective Date Deluxe 1000 Co-Pay Deluxe 2000 Co-Pay Deluxe 3000 Co-Pay Deluxe 4000 Co-Pay Colorado-mandated plan(s) (choose only one plan): PPO Basic Classic PPO Standard Deluxe Please select your deductible period Calendar Year (January - December) HSA 4000 HSA 5000 HSA HRA 5000 HRA Plan Year (Effective Date to Renewal Date) / (Your actual effective date will be assigned during the underwriting process) MM/YYYY 1

4. Please Provide Your Group Information A. Number of Employees Total number of employees (including employed owners/officers) Number of eligible full-time employees (minimum of 24 hours per week, not including those working on a temporary or substitute basis) How many work or live outside the state of Colorado? How many have met the required probationary/waiting period? Number of eligible ENROLLING employees: Number of eligible employees DECLINING coverage: Number of INELIGIBLE employees: Reason for ineligibility: Will coverage be restricted to a certain classification of employees or employees working a certain number of hours per week? If yes, please explain what class(es) or number of work hours are required (must be at least 24 hours): B. Probationary Period/Waiting Period for Employees 1st of month after hire date 1 month 2 months 3 months 4 months 5 months 6 months C. Is your group currently subject to State Continuation of Coverage? (Employed 1-19 eligible employees on at least 50% of its working days in the previous calendar year; or if not in business during any part of the previous calendar year and employed 1-19 eligible employees on at least 50% of its working days during the previous calendar quarter; and not subject to COBRA.) D. Is your group currently subject to COBRA? (Employed 20 or more total employees on at least 50% of the working days in the previous calendar year and not subject to State Continuation of Coverage) E. Is your group subject to the Family Medical Leave Act of 1993? (50 or more total employees) F. Unemployment Insurance Tax Report (UITR) A copy of the employer s most recent Colorado quarterly tax document must be included with the Employer Application. G. Is your group a business group of one? If you are a business group of one, was your prior health coverage Group or Individual? Group Individual If Individual: Please indicate the length of time covered: H. Is this a carve out? If, please describe. Important tice: If you have answered yes to questions C, D, or E please complete the State Continuation of Coverage/COBRA/FMLA questionnaire in section 9. 5. Group Medical History A. Has this group had group health coverage within 90 days of this application s signature date? B. Will this plan replace any existing group coverage? If yes, Current Carrier name: Termination Date: Policy number: C. Have you purchased health benefit coverage as a small employer that is either self-funded or insured through a health benefit plan that is not a small group during the 12 months prior to application with SeeChange Health Insurance? D. Are there employees applying for coverage who are unable to work due to injury or illness? Number of these employees: : Anticipated return date: : Anticipated return date: 2

If necessary, please attach a list of additional employees applying for coverage, but unable to work due to injury or illness to this form. 6. Bank Information SeeChange Health standard payment policy requires payment through ACH. The deduction from your account will be processed on the 10th of each month in which payment is due (or the next business day). Please provide the necessary information below to facilitate this payment. If you opt out of this payment policy and decide to pay by check, payment is due by the first day of the month. Should you wish to have your first month s premium deducted from your bank account, please select below and inlcude a voided. company check Do you agree to pay premiums via an ACH withdrawal? of the bank on the account Routing Number Account Number The Company opts out of ACH payment and acknowledges that payment by check received after the first of the month may result in cancellation of the group policy in accordance with Colorado law. 7. Employee Leave of Absence Policy Number of months, employees are eligible to continue group coverage while on an employer-approved temporary personal leave of absence (maximum 3 months) ne 1 month 2 months 3 months Number of months, employees are eligible to continue group coverage while on an employer-approved temporary medical leave of absence (maximum 6 months) ne 1 month 2 months 3 months 4 months 5 months 6 months 8. Workers Compensation Coverage Current carrier: Next renewal date: Please list the name and job title for any medically enrolling employee under the SeeChange Health Plan who is not an employee for the purpose of Workers Compensation law or similar legislation (definition below). Please attach additional pages if necessary. of the employee: Job Title: Exempt per definition below Definition: Under Colorado law, corporate officers, LLC members, sole proprieters, and partners may choose to reject workers compensation coverage on an employer policy if they have completed a Colorado Owner Exclusion Form and filed it with their workers compensation insurance company. 3

9. Broker Information (to be completed by your broker) I hereby certify: That I am not aware of any information not disclosed in this application by the client which may have bearing on this risk. That I have advised the client not to terminate any existing coverage until receiving written notification from SeeChange Health that the coverage being applied for by this application is accepted. That I have no knowledge the client has entered into any other agreements to wrap supplemental coverage around SeeChange Health products. This includes any HRA accounts, self-funded wrap plans or other similar products. The one exception to the above statement is the HRA 5000 Plan. SeeChange Health allows employers to contribute into a Health Reimbursement. Account on the HRA 5000 Plan. Writing Broker Second Writing Broker Broker of Record is Broker Broker of Record is Broker Is the Broker of Record Appointed with SeeChange Health? Is the Broker of Record Appointed with SeeChange Health? SeeChange Broker ID Number SeeChange Broker ID Number Address Address City, State, Zip City, State, Zip Phone Phone Email Email Fax Fax Signature Signature Date Date Commission Percentage % Commission Percentage % Broker Signature Broker Signature General Agent Information General Agent Broker ID Number Address City, State, Zip Email Send Administration kit to: Group Broker General Agent 4

10. Colorado State Continuation Coverage/COBRA/FMLA Information State Continuation of Coverage: Colorado law requires employers with 2-19 eligible qualified employees to extend health coverage programs to former employees spouses (widowed/divorced), common law spouses, domestic partners, and their dependents when a qualifying event occurs. COBRA: The Federal Consolidated Omnibus Budget Reconciliation Act (COBRA) requires most employers with 20 or more total employees to extend health coverage programs to former employees, spouses (widowed/divorced), and their dependents when a qualifying event occurs, unless the former employee, spouse or dependent was not eligible for continuation of coverage prior to January 1, 2005. FMLA: The Family and Medical Leave Act of 1993 requires groups with 50 or more employees to provide up to 12 weeks of unpaid, job-protected leave to eligible employees for certain family and medical reasons. State Continuation of Coverage and COBRA A. Complete for each employee or family member currently on State Continuation of Coverage or COBRA. (If additional space is needed to include all applicable employees, please use a photocopy of this page) Birth date Qualifying even description Qualifying event date B. State Continuation of Coverage -Complete for each employee terminated in the last 60 days who has had a qualifying event. COBRA- Complete for each employee terminated in the last 90 days who has had a qualifying event. (If additional space is needed to include all applicable employees, please use a photocopy of this page) Termination Date Qualifying event description To the best of your knowledge, will this employee/dependent exercise their State Continuation of Coverage option? To the best of your knowledge, will this employee/dependent exercise their COBRA option? Is this employee/dependent presently disabled? If yes, describe disabling condition Termination Date Qualifying event description To the best of your knowledge, will this employee/dependent exercise their State Continuation of Coverage option? To the best of your knowledge, will this employee/dependent exercise their COBRA option? Is this employee/dependent presently disabled? If yes, describe disabling condition C. FMLA: Complete for each employee on family or medical leave. (If additional space is needed to include all applicable employees, please use a photocopy of this page) Beginning Date of Leave To the best of your knowledge, will this employee return to work? If no, is this employee presently disabled? If yes, describe disabling condition _ To the best of your knowledge, will this employee/dependent exercise State Continuation of Coverage option? 5

11. Signature and Declarations This Employer Application shall be the basis for the issuance of coverage under the Policy and Certificate and shall become a part thereof. SeeChange Health reserves the right to terminate group coverage or the coverage of any Covered Person if the Enrolling Group or individual Covered Person has made any material misrepresentation. PAYMENT OF POLICY CHARGE: Policy Charges and/or fees are due on the first day of each month for which coverage is provided. Delinquent payments shall be subject to late charges of one and one-half percent per month. If payment is not received from the Enrolling Group, coverage for all Covered Persons will be terminated on the last day of the month for which Policy Charges were received. Termination of coverage, including cancellation due to nonpayment of Policy Changes, may be applied retroactively. Any other payment arrangements require prior approval by SeeChange Health. If a Covered Person receives medical services after coverage is terminated or lapses, the Covered Person is responsible to reimburse SeeChange Health for any payments made by SeeChange Health for such services. VERIFICATION OF ELIGIBILITY: Verification of eligibility does not guarantee payment of claims. Retroactive eligibility changes supersede verifications of eligibility. CHANGES IN PARTICIPATION OR POLICY CHARGE PERCENTAGES: Coverage and Policy Charges are based, in part, on the number of Covered Persons, the percentage of Employees and Dependents participating and the percentage of Policy Charge paid by the Employer. If any of these fall below levels accepted by SeeChange or below the level upon which the Policy Charge has been based, SeeChange Health may terminate the coverage by giving notice to the Enrolling Group. REQUIREMENT FOR BINDING ARBITRATION. Except for class action matters, the Group agrees that if coverage is provided pursuant to an employer-sponsored benefit plan that is exempt from the Employee Retirement Income Security Act of 1974 (ERISA) or if a dispute exists that is not governed by ERISA that the Group will be subject to binding arbitration. By signing this Employer Application, the Group understand that SeeChange Health requires binding arbitration to settle all disputes including, but not limited to, disputes relating to the delivery of service under the Policy or any other issues related to the Policy and claims of medical malpractice, if the amount in dispute exceeds the jurisdictional limit of small claims court. In cases of a medical malpractice claim or dispute for which the total amount of damages claimed is fifty thousand dollars ($50,000) or less, a single, neutral arbitrator shall be selected who shall have no jurisdiction to award more than fifty thousand dollars ($50,000). If the parties are unable to agree on the selection of a single neutral arbitrator, the method provided in 13-22-211 of the Colorado Uniform Arbitration Act, C.R.S shall be utilized. The Group agrees that any dispute for which the total amount of damages claimed is in excess of fifty thousand dollars ($50,000), or disputes relating to the delivery of services under the Policy or any other issue related to the Policy, including any dispute as to medical malpractice, that is as to whether any medical services rendered under the Policy were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by the applicable rules of the American Arbitration Association. In order to begin the arbitration process, the Group or a Covered Person shall give written notice to each party explaining the dispute and the amount involved, if any, and the solution desired. The Group or Covered Person must then file a copy of the notice with the American Arbitration Association s regional office 1400 16th Street, Suite 400, Denver, CO 80202, along with the fee required by the American Arbitration Association. 6

The Group agrees that by signing this Policy that the Group understands that it is giving up the constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. This means that the Group and Covered Persons are waiving the right to a jury trial for both medical malpractice claims, and any other dispute including disputes relating to the delivery of service under the Policy or any other issues related to the Policy. I certify that all the information contained in this application is correct to the best of my knowledge and all participation requirements have been met, and if I have misrepresented or omitted any material fact, coverage may be cancelled and the contract rescinded. I also acknowledge that I have no knowledge of the below mentioned entity entering into any other agreements to wrap supplemental coverage around SeeChange Health products. This includes any H.R.A. accounts, self-funded wrap plans or other similar products. I also authorize and understand that SeeChange Health Insurance Company, Inc., may access personal health information when necessary to conduct underwriting reviews at the time of enrollment or at subsequent renewals. SeeChange does not share your personal health information with anyone unless permitted or required by law. I certify that all coverage, enrollment provisions, eligibility requirements, benefits, limitations and exclusions have been thoroughly explained to eligible employees. I certify that I have read, understand and concur with the provisions of this declaration. The one exception to the above statement is the 5000 HRA Plan. SeeChange Health allows employers to contribute up to 50% of the out-of-pocket maximum into a Health Reimbursement Account on the 5000 HRA Plan. As a company principal/corporate officer having authority to contract with SeeChange Health Insurance Company, I agree that our prepaid monthly dues will be submitted by the last working day of each month, prior to the month of coverage, and I will abide by the contract provisions, as set forth in the group agreement issued by SeeChange Health and the group insurance policy issued by SeeChange Health. I consent that any person may give information to SeeChange Health concerning the principal owners' and stockholders' credit history. It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial or insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Employer Legal Entity : of the Employer Office/Owner: Title Signature of Employer Officer/Owner: Date COLORADO INSURANCE LAW REQUIRES ALL CARRIERS IN THE SMALL GROUP MARKET TO ISSUE ANY HEALTH BENEFIT PLAN IT MARKETS IN COLORADO TO SMALL EMPLOYERS OF 2-50 EMPLOYEES, INCLUDING A BASIC OR STANDARD HEALTH BENEFIT PLAN, UPON THE REQUEST OF A SMALL EMPLOYER TO THE ENTIRE SMALL GROUP, REGARDLESS OF THE HEALTH STATUS OF ANY OF THE INDIVIDUALS IN THE GROUP. BUSINESS GROUPS OF ONE CANNOT BE REJECTED UNDER A BASIC OR STANDARD HEALTH BENEFIT PLAN DURING OPEN ENROLLMENT PERIODS AS SPECIFIED BY LAW. Employers with 10 or more eligible employees are entitled to a choice of composite rates of four-tier family, or age-banded rates. Employers have the right to see premium quoted either way. The total premium will initially be the same based on the enrollment assumption used to prepare the quote. However, subsequent enrollment changes may result in premium differences depending on the rate method selected. CO - ERA 1-50 20120701 SeeChange Health Insurance Company, Inc. 7