Employer Application For employer groups with 2-50 employees P.O. Box 14326 Reading, PA 19612 www.seechangehealth.com Main: 888-228-4580 Fax: 559-244-0458 Enroll@SeeChangeHealth.com 1. Company Information Company Group. (For existing groups) Street Address City State Zip Code Billing Address Same as Street Address City State Zip Code Business Organization Corporation Sole Proprietorship LLC Type of Business (Please be specific) Partnership Other, please specify 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 the company will contribute toward employee and dependent premiums Employee % Dependent % (50% -100%) (0% - 100%) 3. Benefit Plan And Effective Date Please select the benefit plan and the desired effective date Classic 2200 Deluxe 500 Co-Pay -Deductible 3.0 HSA 3000 HRA 5000 Classic 3500 Deluxe 1000 Co-Pay -Deductible 6.0 HSA 4000 Select 8000 Classic 5000 Deluxe 2000 Co-Pay -Deductible 9.0 HSA 5000 Select 10000 Deluxe 3000 Co-Pay Deluxe 4000 Co-Pay Employee Option Program - Must have at least 5 enrolling employees to be eligible. *te: Employee may ONLY select within chosen plan level Classic Deluxe -Deductible HSA Select HRA Requested Effective Date / (Your actual effective date will be assigned during the underwriting process) MM/YYYY
4. Please Provide Your Group Information A. Number of Employees Permanent full time employees Total Enrolling 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 Cal-COBRA) who are actively at work for at least 30 hours per week: Permanent part time employees who are actively at work E. Is your group subject to the Family Medical Leave Act of 1993? (50 or more total employees) 20-29 hours per week: Other ineligible employees: Total: F. DE-6. A copy of the employer s most recent California document must be included with the Employer Application. 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 Cal-COBRA? (Employed 2-19 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 2-19 eligible employees on at least 50% of its working days during the previous calendar quarter; and not subject to COBRA.) G. Covering part time employees? Please indicate whether part time employees working 20-29 hours/week will be covered under the SeeChange plan. 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 Cal-COBRA/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. 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: 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 (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. 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 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 California Labor Code Section 3351, partners, corporate officers and members of boards of directors are employees for Workers Compensation purposes except under limited circumstances. In order for individuals holding the above mentioned positions to fall outside the Workers Compensation laws, they must be shareholders of the corporation, and all stock of the corporation must be held by persons who are either officers or members of the board of directors of the corporation.
9. 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 the SeeChange Health products. This includes any H.R.A. accounts, gap policies, supplementary policies or any other similar products. The one exception to the above statement is the HRA 5000 Plan. SeeChange Health allows employers to contribute up to 50% of the deductible into a Health Reimbursement Account on the HRA 5000 Plan. / ID Number / ID Number of Record is of Record is Address Address City, State, Zip City, State, Zip Phone Phone Email Email Fax Fax Signature Signature Date Date Commission Percentage % Commission Percentage % Signature Signature General Agent Information General Agent ID Number Address City, State, Zip Email Send Administration kit to: Group General Agent
10. Cal-COBRA/COBRA/FMLA Information Cal-COBRA: California law requires employers with 2-19 eligible qualified employees to extend health coverage programs to former employees spouses (widowed/divorced), and their dependents when a qualifying event occurs. 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. 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. Cal-COBRA and COBRA A. Complete for each employee or family member currently on Cal-COBRA 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. Cal-COBRA-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 Cal-COBRA 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 Cal-COBRA 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 Cal-COBRA option? 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 Section 1281.6 of the Code of Civil Procedure shall be utilized. The Group agrees that any dispute including 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 in San Francisco, California (415-981-3901), along with the fee required by the American Arbitration Association.
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 the SeeChange Health products. This includes any H.R.A. accounts, gap policies, supplementary policies or any 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 HRA 5000 Plan. SeeChange Health allows employers to contribute up to 50% of the deductible into a Health Reimbursement Account on the HRA 5000 Plan. Employer Legal Entity : of the Employer Office/Owner: Title Signature of Employer Officer/Owner: Date S-ERA2-50-20110607 SeeChange Health Insurance Company, Inc.