Universal Employer Group Application Package Coventry Health and Life Insurance Company, Coventry Health Care of Florida, Inc. (hereinafter referred to as Coventry ). Coventry may be referred to as Plan. Instructions 1. COMPLETE ALL QUESTIONS IN FULL. INCOMPLETE APPLICATIONS WILL DELAY PROCESSING. Employer must complete entire application. 2. PRINT CLEARLY USING INK. 3. DO NOT MODIFY, ADD, OR DELETE ANY PART OF THIS FORM. 4. SIGN AND DATE APPLICATION. Application must be signed and dated by owner or officer of the company requesting coverage and Agent 5. SUBMIT THE FOLLOWING ITEMS TO YOUR AGENT AND/OR COVENTRY REPRESENTATIVE: Completed Application Premium deposit made payable to applicable company: Coventry Health and Life Insurance Company, Coventry Health Care of Florida, Inc. UCT-6 (most recent available) Current premium statement from current health plan carrier Employee Applications Other requested supporting documentation (if applicable) Selected rates and corresponding Benefit Plan Summaries as proposed by Coventry A small group is any group with 50 or fewer full-time eligible employees (working 25 hours or more per week) as defined by Florida Statute 627.6699, as may from time to time be amended. DO NOT CANCEL EXISTING COVERAGE UNTIL NEW GROUP COVERAGE WITH COVENTRY IS EFFECTIVE. Coverage will not commence until the application is approved by Coventry and the conditions of coverage are accepted by the employer. 1
Coventry Health and Life Insurance Company Coventry Health Care of Florida, Inc. Effective Date SubGroup Number A) Employer Group Information (mailing address same address as in Section F? Yes No ) Company Name DBA Tax ID Number (required) SIC Code Address (physical location) City State Zip Contact Name (Group Administrator) E-mail address Telephone Fax Decision Maker Name E-mail address Telephone Fax Employer Classification: Corporation Non-Profit Partnership Sole Proprietor LLC LLP Other: Number of years with current carrier:. Number of carriers within the past 5 years:. Are multiple companies or multiple addresses to be included under this plan? Yes B) Prior Coverage Information check all that apply Types of Coverage HMO POS PPO HSA HRA ASO Other Will you offer any other health carrier, other than Coventry? Yes No No Name of Prior Carrier If yes, please explain: C) Workers Compensation Coverage Do you currently have a workers compensation policy in force? Yes No Policy Renewal Date: List current workers compensation carrier: Policy Number:. Are all employees covered under workers compensation? Yes No If no, please explain:. Please list the name and job title of all individuals to be included for medical coverage who are not eligible for workers c ompensation: Name Title 1) 2) 3) 2
D) Employee Eligibility (medical probationary waiting period must not exceed 90 days) Employee Eligibility by Class according to Federal health care reform, an employer s group health plan cannot discriminate in favor of highly-compensated employees. Doing so may result in a penalty. To avoid penalties, please review any class-based benefits with your legal or financial advisor to ensure your group health plan does not favor highly compensated employees. (Excludes grandfathered health plans.) Waive waiting period on initial installation? Yes No For small group pick only one class and waiting period for ALL employees. New Hires - Description Commence coverage (check one per class) Waiting Period (check one per class) (no waiting period beyond 90 days) Class 1 Immediately or after: 30 days other 1 st of the month following (90 days not applicable): 30 days 60 days other Class 2 Immediately following: 30 days 60 days 90 days other 1 st of the month following: 30 days 60 days Class 3 Immediately following: 30 days 60 days 90 days other 1 st of the month following 30 days 60 days Employee Termination (one option applied to all classes listed above) Employee terminations will be effective (large group): end of the month date of termination For small group employee terminations will be effective end of the month. E) Payment Employer herewith tenders the amount $. In the event the Plan approves coverage for the Employer Group, the Employer shall pay the Plan any balance necessary to constitute the full initial payment for the group benefits herein identified. Employer understands that final rates will be determined by the Plan from actual enrollment data and coverage will not commence until the application is approved by the Plan and the conditions of coverage are accepted by the Employer. F) Billing Option/Division Billing address only if different from Section A. Attach a separate sheet of paper signed and dated, using the same format as below for multiple locations. Are there multiple units/locations to be billed separately? Yes No If yes, list names and addresses of all multiple units/locations to be billed separately. Division Name Contact 1 Billing Address (if different) City State Zip E-mail address Telephone Fax Division Name Contact 2 Billing Address (if different) City State Zip E-mail address Telephone Fax G) Underwriting 1. Number of employees on payroll. 2. Have you been covered by Coventry in the last 3 years? Yes No 3. Does the organization have or intend to have a PEO or leased employees? Yes No 4. Are there any affiliates or subsidiaries as defined in IRS sec 414? Yes No If yes, are all affiliates or subsidiaries enrolling? Yes No 5. Are all eligible employees being offered health coverage? Yes No If no, please explain: Does the contracting entity have a flex plan under Section 125 or 132 of the IRS code? Yes No COBRA/State Continuation: Please indicate number of participants: Federal COBRA or State Continuation (mini-cobra). Applications are required for all COBRA and State Continuation participants. RETIREES (applies to large group only): Are there any retirees being offered this Coventry coverage? Yes No If yes, they are subject to underwriting approval. 3
COMPOSITE RATES H) Health Care Reform Classification Medical Loss Ratio (MLR) Classification. Check the appropriate box below. More information about Health Care Reform can be found at www.hhs.gov. ERISA Government Group Non-Federal (A non-federal governmental plan is a plan that is established or maintained by the government of any state or political subdivision thereof for its employees, or by any agency or instrumentality of any government of any state or political subdivision for its employees); Non-ERISA and not a Government Group - church groups, workers compensation plans, unemployment, or disability laws, non-resident of USA or unfunded excess benefit plans (if you choose this option you must complete the Coventry non-erisa addendum that will be provided and check one of the boxes below); Non-ERISA Agree to the terms in the Coventry non-erisa addendum; Non-ERISA Don t agree to the terms in the Coventry non-erisa addendum Average # of Employees Example: January 1 through December 31. This average must include all persons employed by the company and any affiliated companies in the preceding calendar year, whether an employee was full-time, part-time, and/or seasonal. Important: the government requires the total average number, regardless of whether employees were eligible to enroll, and/or participated in the group insurance coverage. Only include temporary employees of the company in the FT or PT monthly count if they are employees (i.e., employees to whom the employer issues a W-2). Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Average FT Emp. PT Emp. Seasonal Total Average = the total number of employees for the previous calendar divided by 12 months (e.g., total divided by 12) I) Plans/Rates Selected Benefit Plan Name IDX Number: LOB: (e.g. HMO, POS, PPO) Coventry Consumer Choice (C3) product (FSA, HRA, FSA) EE ES EC FM Check here if table rates apply. Table rate sheet must be signed and returned to Coventry prior to being approved for coverage. NOTE: Please attach Coventry quote(s) page(s). J) Employer Funding (if applicable) Please list the amount that the employer is funding toward the employee s single / family deductible. I certify that I am funding $ (single) / (family) of my employee s plan: (name of plan) Employer Contribution: Please provide the Employer contribution. Employee ($ or %) Premium rates may be adjusted based on the employer s subsidy of the deductible. K) Employer/Plan Sponsor Statement of Understanding and Certification Eligibility: A bona-fide employee/employer relationship must be maintained. Employer/Plan Sponsor must continually compensate the individual in the form of annual, weekly or hourly wages. An eligible employee is an employee who works full-time, having a normal workweek of twenty-five (25) or more hours, unless otherwise on leave in accordance with the Family Medical Leave Act or other applicable law and the Employer s Contract. Furthermore, Employer/Plan Sponsor and Employee must maintain an employment relationship pursuant to which Employer/Plan Sponsor pays those payroll costs (e.g. FICA, FUI, SUI and Workers' Compensation) normally associated with a bona-fide employee relationship. Any other eligibility arrangements require prior approval by the Coventry Underwriting Department. If an employee becomes ineligible for coverage under the group coverage for any reason, Employer/Plan Sponsor must terminate such 4
employee s employment and offer COBRA or State Continuation benefits in accordance with applicable law. Premiums: All premiums are due in full on the first (1 st ) of each month for which coverage is provided. If total payment is not received from Employer/Plan Sponsor during the grace period, coverage for all enrollees will be terminated on the last day of the month for which premiums were received, not to exceed 45 days retroactively. For large groups, terminations retroactive over 90 days are not accepted. For small groups, terminations retroactive over 30 days are not accepted. Any other payment arrangements require approval by Coventry. The initial quoted premiums determined by Coventry are based on information provided to Coventry by Employer/Plan Sponsor and/or its representative. Premiums are subject to change annually on the anniversary of the effective date of coverage or as otherwise agreed to by Coventry and the Employer/Plan Sponsor. Notice of premium changes will be provided prior to renewal in accordance with applicable law. In the event that Employer/Plan Sponsor continues coverage under the applicable Binder and Agreement, all applicable terms and conditions set forth in this Application shall survive in full force and effect and be binding on the Employer/Plan Sponsor. When payment is made by check, Employer/Plan Sponsor hereby authorizes Coventry either to use information from the check to make a one-time electronic fund transfer from the Employer/s/Plan Sponsor s account or to process the payment as a check transaction. When Coventry uses information from the check to make an electronic fund transfer, funds may be withdrawn from the account as soon as the same day Coventry receives payment, and Employer/Plan Sponsor will not receive the check back from the financial institution. Employer/Plan Sponsor Statement: I have read and understand the terms of this Application. By signing this application, I agree to these terms. I certify that the information I have provided on this Application is true and complete to the best of my knowledge. Coventry will rescind coverage only due to an act or practice constituting fraud or an intentional misrepresentation of a material fact. In the event of a rescission of your coverage, Coventry shall not be financially liable for any services rendered to you and will seek remedies to recover any claims paid by Coventry for such services. I am duly authorized to execute this Application. This Application, the medical questionnaire or Risk Appraisal Questionnaire and all information provided by Employer/Plan Sponsor, the Binder and Agreement and the Certific ate of Insurance/Certificate of Coverage shall collectively be referred to as the Contract and shall be deemed the basis for Coventry s issuance of coverage. If accepted for coverage, Coventry will rescind coverage only due to an act or practice constituting fraud or an intentional misrepresentation of a material fact. In the event of a rescission of coverage, Coventry shall not be financially liable for any s ervices rendered to such rescinded group or for any individual member to the coverage effective date and will seek remedies to reco ver any claims paid by Coventry for such services. To the extent that any provision of this Application is inconsistent with the terms of the Binder and Agreement, this Application shall prevail, as permitted by law. I hereby agree to obtain a Certificate of Insurance/Certificate of Coverage (or Certificate ) through the Coventry website at chcflorida.com or by calling the Coventry Customer Service Department at 1-866-847-8235 and requesting a hardcopy be mailed via U.S. regular mail. Employees must obtain a copy of the Certificate through the website, contacting the Group Benefit Administrator, or by calling the Customer Service Department and requesting a hard copy be mailed via U.S. regular mail. I hereby agree to provide a copy of the Certificate to all employees who request the Certificate. I hereby agree that the continuation of premium payments will be considered as acceptance of group renewal and enforcement of th e Contract and all amendments to the Contract, including but not limited to rate or benefit changes, as determined by Coventry. Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information may be guilty of a felony of the third degree. Dated at (city) this day of 20 Print Name Title Authorized Employer Signature (Officer or Owner Only) L) Agent Information and Certification Agent Name Agent FL License # IRS Number Agent Address Phone E-mail Address Agent Statement: I certify that all the information contained in this application is correct to the best of my knowledge. I certify that the applicant is a bona-fide business establishment. I certify that all participation and contribution requirements are met. I certify that all coverage, enrollment provisions, eligibility requirements, benefits, limitations and exclusions have been thoroughly explained to Employer. I recommend that such coverage be offered and know of no reason why coverage should be declined. Dated at (city) this day of 20 Print Name Title Agent Signature X M) For Coventry use only Account Executive Signature Date Group #: Parent Code #: Sales Management Signature Date Underwriting Signature Date Enrollment Signature Date If applying for HMO or POS coverage, primary business locations must be in a Coventry approved service area. The underwriting guidelines are applied collectively for all products selected under this Application and purchased by the Employer/Plan Sponsor. 5