NY Sole Proprietor Application

Transcription

1 NY Sole Proprietor Application Liberty Plan SM Direct 30/50 Liberty Plan SM EPO 25/50 FreedomPlan Direct HSA $2,850 Freedom Plan EPO HSA $2000 Enrollment Mailing Address: 180 East Main Street, Suite 205, Patchogue, NY I. G E N E R A L I N F O R M A T I O N 1. Full Legal Name of Group: 2. Primary Address of Group: (Street Address City, State, ZIP Code) *No P.O. Box 3. Plan Administrator/Contact: a. Name b. Title c. Address (If different from primary) City, State, ZIP Code d. Phone Number Ext. e. Fax Number f. Address g. Add l Contact & Number 4. Name and title of person to receive billing statements: a. Name b. Title c. Address (If different from primary) City, State, ZIP Code d. Phone Number Ext. e. Fax Number 5. Nature of Business: 6. SIC Code: 7. Tax Identification Number: NY Page Rev 2

2 I I. A D M I N I S T R A T I V E I N F O R M A T I O N The term coverage means the benefits provided by Oxford, pursuant to the group Certificate of Coverage. 1. Effective date: We request that this coverage be effective:. (Month / Day 1st / Year) 2. Age of Business: Please indicate if your business has been in operation:. Less than 12 months More than 12 months 3. Other group health or HMO coverage: Indicate below other group health coverage which is still in force or which terminated within the past three years. Type of coverage Name of carrier Effective date If terminated, date terminated 4. Integration with Medicare Benefits: Health benefits covered by Medicare Part A and B are carved out for retired employees age 65 and over and their dependents age 65 and over if the group offers retiree coverage. I I I. P R O D U C T A N D P L A N D E S I G N S A. Oxford Sole Proprietor Plan Instructions: Please select a plan option and check off any variable items as provided below. Liberty Network Freedom Network Benefit Package Plan 1 Plan 2 Plan 5 Plan 3 Plan 4 Product Direct EPO EPO Direct HSA EPO HSA PCP Copayment 30/50 25/50 25/50 N/A N/A In-Network Coinsurance % 80% 90% N/A 90% 100% Out-of-Network Coinsurance % 60% N/A N/A 70% N/A In-Network Single Deductible $2,000 $2,000 N/A $2,850 $2,000 Out-of-Network Single Deductible $2,000 N/A N/A $2,850 N/A Family Multiplier 2x 2x N/A 2x 2x Emergency Room Copayment $100 $75 $75 Deductible and Coinsurance Inpatient Facility Deductible and Coinsurance $300 per day Deductible and Coinsurance to five day max Outpatient Surgical Deductible and Coinsurance $300 per incident Deductible and Coinsurance Prescription Benefit 15/50% with $100 Deductible 15/50% with 15/50% with $2,850 Ded $2,000 Ded Domestic Partner Same and Opposite Same and Opposite B. Other Riders Coverage for Biologically Based Mental Illness and Children with Serious Emotional Disturbances OHINY GA SP 1007 Page Rev 4

3 I V. R A T E I N F O R M A T I O N Monthly Rates: All new groups are subject to the four-tier rate structure indicated below. Rates must be included in the spaces below for application processing. Please note V. B R O K E R / A G E N T I N F O R M A T I O N Broker Co-Broker General Agent 1. Name of Broker/Agent : 2. Oxford Broker Code (Required): 3. Social Security # or Federal Tax ID #: 4. Broker Street Address: 5. City, State, ZIP Code: 6. Telephone Number: 7. Fax Number: 8. Address: 9. Commission Split %: 10. Oxford Sales Representative: Amy Bisson-NHSBU Comments: V I. C O N S E N T AUTHORIZATION FOR BROKER TO ACT AS BENEFITS ADMINISTRATOR The undersigned hereby requests Oxford Health Plans to accept the Broker or General Agent named above as an authorized Benefits Administrator for purposes of processing any enrollment transactions for my company s Oxford Health Plan policy (including, but not limited to, Member enrollments, Member terminations, Member address changes, group contact changes, group address changes, plan renewal changes, and group contract terminations). This authorization shall be effective immediately and shall (check one only): Remain in place until it is expressly revoked by me in writing. Remain in place until. (Month / Day 1st / Year) Further, I agree that my company will be bound by the actions performed by the herein-named Broker or General Agent pursuant to this Consent Form. Additionally, I agree that this Consent Form does not authorize anyone to receive individually identifiable health information about any Oxford Member. I acknowledge that I must notify Oxford in writing to void this agreement in the event of a change in my company s Broker of Record.

4 V I I. C O B R A & E X T E N S I O N O F B E N E F I T S D A T A 1. Do you have any individuals currently on COBRA continuation? Yes No If yes, identify the number of individuals. 2. Are there any dependents of employees who are currently disabled or in the hospital? Yes No 3. What is the length of the prior carrier s extension of benefits period for disabled employees or dependents? V I I I. A P P L I C A N T A G R E E M E N T This Application and the premium rates proposed by Oxford are subject to Home Office approval, in writing, by Oxford and may change due to differences in actual versus proposed enrollment, selection of benefits, changes in census data or underwriting criteria, or any other changes in underwriting as determined by Oxford. The Applicant hereby acknowledges that this Application does not constitute any obligation by Oxford to offer coverage to the Applicant until such Application is accepted, in writing, by the Home Office of Oxford. The Applicant hereby confirms that it will not cancel any current health coverage it may currently have in anticipation that this Application will be accepted by Oxford, and that Oxford shall have no obligation to provide coverage to the Applicant unless this Application is formally accepted, in writing, by the Oxford Home Office. Further, I hereby certify on behalf of the Applicant that the Applicant has not had a group health policy terminated within the past 12 months due to failure to pay premiums. Dated at: this day of 20. Full legal name of firm: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 dollars and the stated value of the claim for each violation. Oxford Health Insurance, Inc. X Signature of Authorized Officer of the Company Title Witness Duly Licensed Resident Agent/Broker OHINY GA SP 1007 Page Rev 4

5 NY Member Enrollment & Physician Selection Form Oxford Health Insurance, Inc. Mailing Address: P.O. Box 7085, Bridgeport, CT Corporate Address: 48 Monroe Turnpike, Trumbull CT Thank you for choosing Oxford Health Insurance, Inc., (Oxford) as the health plan for you and your family. IMPORTANT! Please print and press down firmly when completing this form. In order to process the attached Member Enrollment Form and begin coverage, all the following information must be completed accurately and in its entirety: Date of Employment Date of Marriage, if applicable Date of Birth Social Security Numbers Primary Care Physician selections Other coverage you or your spouse may have Employer and Employee signatures are required at the bottom of form. Complete the Family Health Statement when instructed by your Benefits Administrator. If a dependent is a full-time college student at an accredited school, you must attach proof of full-time student status, such as a paid bill/tuition statement, an Oxford Student Verification Form, or a letter from the registration/bursar s office confirming enrollment. Attach disability paperwork for dependents, if applicable If you have any questions, please feel free to call our Customer Service Department at Thank you again for choosing Oxford. OHINY MEF LS R4

6 NY Member Enrollment Form - Oxford Health Insurance, Inc. Mailing Address: P.O. Box 7085, Bridgeport, CT Corporate Address: 48 Monroe Turnpike, Trumbull CT TO BE COMPLETED BY EMPLOYER NAME OF GROUP (EMPLOYER} GROUP NUMBER CONTRACT SPECIFIC PACKAGE (CSP) BILLING GROUP (BG) PLEASE PRINT EMPLOYEE S EFFECTIVE DATE OF COVERAGE IS THIS INDIVIDUAL ENROLLING UNDER COBRA? IF YES, QUALIFYING EVENT DATE OF QUALIFYING EVENT IS THIS MEMBER DISABLED? / / / / PRODUCT SELECTED: HMO FREEDOM IS EMPLOYEE CURRENTLY: ACTIVELY AT WORK? ON LEAVE OF ABSENCE? RETIRED? LIBERTY LIBERTY HMO OTHER: AVERAGE NUMBER OF HOURS WORKED PER WEEK DATE OF FULL-TIME EMPLOYMENT EMPLOYEE OCCUPATION UNION/NON-UNION EMPLOYER SIGNATURE / / X / / TO BE COMPLETED BY EMPLOYEE EMPLOYEE LAST NAME FIRST NAME & MI MALE DATE OF BIRTH FEMALE / / STREET ADDRESS APT. NUMBER HOME PHONE BUSINESS PHONE DATE ( ) ( ) CITY STATE ZIP COUNTY SOCIAL SECURITY NUMBER OXFORD PRIMARY CARE PHYSICIAN OXFORD CODE IS THIS A NEW PHYSICIAN FOR YOU? OXFORD OB/GYN PROVIDER (FEMALE MEMBERS) OXFORD OB/GYN CODE IS THIS A NEW PHYSICIAN FOR YOU? TYPE OF COVERAGE: SINGLE FAMILY ANY OTHER HEALTH COVERAGE (INCLUDING MEDICARE) WHILE ENROLLED WITH OXFORD? SOCIAL SECURITY NUMBER OF POLICY HOLDER COVERAGE DATES PARENT / CHILD HUSBAND / WIFE IF YES, CARRIER NAME: / / TO / / LANGUAGE: ENGLISH SPANISH COMMUNICATION PREFERENCE (PLEASE RANK IN ORDER FROM 1-4) PREFERRED TIME/ PLACE OF CONTACT CHINESE OTHER: MAIL FAX PHONE - ADDRESS: DAY EVENING HOME OFFICE EMPLOYEE S DEPENDENT INFORMATION SPOUSE S LAST NAME FIRST NAME & MI DATE OF BIRTH SOCIAL SECURITY NUMBER MALE DATE OF MARRIAGE: / / FEMALE / / IS THIS DEPENDENT DISABLED? ANY OTHER HEALTH COVERAGE SOCIAL SECURITY NUMBER OF POLICY HOLDER COVERAGE DATES IF YES, NAME: / / TO / / SPOUSE S EMPLOYER SPOUSE S OCCUPATION DAYTIME PHONE OXFORD PRIMARY CARE PHYSICIAN OXFORD CODE IS THIS A NEW PHYSICIAN FOR YOU? OXFORD OB/GYN PROVIDER (FEMALE MEMBERS) OXFORD OB/GYN CODE IS THIS A NEW PHYSICIAN FOR YOU? ELIGIBLE CHILD S LAST NAME FIRST NAME & MI DATE OF BIRTH SOCIAL SECURITY NUMBER MALE AGE: ( ) / / FEMALE IS THIS DEPENDENT DISABLED? ANY OTHER HEALTH COVERAGE SOCIAL SECURITY NUMBER OF POLICY HOLDER COVERAGE DATES IF YES, NAME: / / TO / / OXFORD PRIMARY CARE PHYSICIAN OXFORD CODE IS THIS A NEW PHYSICIAN FOR YOU? OXFORD OB/GYN PROVIDER (FEMALE MEMBERS) OXFORD OB/GYN CODE IS THIS A NEW PHYSICIAN FOR YOU? ELIGIBLE CHILD S LAST NAME FIRST NAME & MI DATE OF BIRTH SOCIAL SECURITY NUMBER MALE AGE: / / FEMALE IS THIS DEPENDENT DISABLED? ANY OTHER HEALTH COVERAGE SOCIAL SECURITY NUMBER OF POLICY HOLDER COVERAGE DATES IF YES, NAME: / / TO / / OXFORD PRIMARY CARE PHYSICIAN OXFORD CODE IS THIS A NEW PHYSICIAN FOR YOU? OXFORD OB/GYN PROVIDER (FEMALE MEMBERS) OXFORD OB/GYN CODE IS THIS A NEW PHYSICIAN FOR YOU? ELIGIBLE CHILD S LAST NAME FIRST NAME & MI DATE OF BIRTH SOCIAL SECURITY NUMBER MALE AGE: / / FEMALE IS THIS DEPENDENT DISABLED? ANY OTHER HEALTH COVERAGE SOCIAL SECURITY NUMBER OF POLICY HOLDER COVERAGE DATES IF YES, NAME: / / TO / / OXFORD PRIMARY CARE PHYSICIAN OXFORD CODE IS THIS A NEW PHYSICIAN FOR YOU? OXFORD OB/GYN PROVIDER (FEMALE MEMBERS) OXFORD OB/GYN CODE IS THIS A NEW PHYSICIAN FOR YOU? RACE/ETHNICITY (OPTIONAL) (THIS INFORMATION IS FOR THE PURPOSE OF DATA COLLECTION AND WILL NOT BE USED FOR DETERMINING ELIGIBILITY, RATING OR CLAIM PAYMENT.) EMPLOYEE: WHITE AFRICAN AMERICAN/BLACK HISPANIC/LATINO ASIAN OTHER: SPOUSE: WHITE AFRICAN AMERICAN/BLACK HISPANIC/LATINO ASIAN OTHER: CHILD: WHITE AFRICAN AMERICAN/BLACK HISPANIC/LATINO ASIAN OTHER: CHILD:: WHITE AFRICAN AMERICAN/BLACK HISPANIC/LATINO ASIAN OTHER: CHILD: WHITE AFRICAN AMERICAN/BLACK HISPANIC/LATINO ASIAN OTHER: IN ORDER TO HELP US QUICKLY PROCESS THIS FORM AND AVOID DELAYS, PLEASE MAKE SURE ALL AREAS ARE PROPERLY FILLED OUT. IF YOU HAVE ADDITIONAL DEPENDENTS, PLEASE USE ANOTHER ENROLLMENT FORM TO PROVIDE THE NECESSARY INFORMATION. I understand that my enrollments and benefits are in accordance with those described in the Oxford Health Insurance Certificate. I understand that, in order to receive in-network benefits, I and any enrolled dependents must seek care through our Oxford affiliated primary care physician or through an Oxford-affiliated specialist physician with an authorized referral from the primary care physician if required. I further understand that if I do not adhere to these requirements, I will be eligible only for out-of-network health insurance coverage under the terms of the Certificate. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. X EMPLOYEE/APPLICANT SIGNATURE DATE OHINY MEF LS 805 WHITE COPY: OXFORD PINK COPY: OFFICE YELLOW COPY: EMPLOYER GREEN COPY: EMPLOYEE/MEMBER 4318 R4

7 Health Savings Account Employer Set-up Bank Notification Instructions: If the Employer Group elects to promote OptumHealthBank Health Savings Accounts, this form is to be used during implementation to (a) gather information from the Employer Group about their requirements for a Health Savings Account (HSA), and (b) inform OptumHealthBank that a case has been sold and provide information about the Employer Group s HSA requirements. A definitions list for all data requested on this form is on page 3. * denotes a required field, all required fields must be completed or the form will be rejected and sent back to the submitter. The completed form is to mailed to Oxford Health Insurance 14 Central Park Drive, Hooksett, NH * Attn: Group Enrollment Department. New Form Updated Form Date Submitted: Base Medical Policy # (Group ID):* 1 Employer Information Employer Name:* Employer Address 1:* Employer Address 2: City:* State:* Zip Code:* Broker Agency Name: Broker Agency Tax ID #: - - Broker Agency Address: Broker Agency Contact Name: Broker Agency Phone #: ( ) - Broker Agency Fax # :( ) - Broker Agency Broker Name: Broker ID/License #: - - Broker Address: Broker Phone #: ( ) - Broker Fax # :( ) - Broker Policy Information Effective Date of High Deductible Health Plan:* / / Case Sold Date: :* / / Projected Number of HSA Accounts: As of Date: / / 3 - Enrollment Information Method of Enrollment:* (must select one of the following as the primary enrollment method) Online Paper Batch File If Batch* - Standard Format Non-standard format (If Non-standard, include approved PRP in #9) If Batch* Will employer obtain OptumHealth HSA Affirmation? Yes No Open Enrollment Meeting Date: / / Enrollment Year:* Open enrollment period from: : / / to : / / Open enrollment HSA phone number: ( ) - Is the employer contract signed?: Yes No (applicable only to employers who select Batch with Affirmation enrollment method) 4 - Will Payroll deductions be transferred into the Employee s account?* Yes No 5 - Will Employer be Contributing to the Employee s HSA account?* Yes No Page 1 of R4

8 6 Contribution Method Health Savings Account Employer Set-up Bank Notification ACH Direct Deposit via payroll Combined Sum ACH Wire Check 7 - Contribution Frequency (if applicable) Weekly Semi-monthly Monthly Other 8 Will Employer Want to Receive a Listing of Employee Account Numbers? (Required * if yes to #4 &/or #5) Yes No Account Number File Recipient Name: Phone #: ( ) - Frequency: Weekly Semi-weekly Monthly 9 Approved PRP Requests (for OptumHealthBank use only) Is a PRP request associated to Employer Group?: Yes No (If PRP = Yes Please enter PRP number(s) below) PRP #: PRP #: PRP #: Brief Description: Brief Description: Brief Description: Comments: 10 - Contact Information 1. Form Submitter:* Phone #:* ( ) - 2. Primary Contact (HR Contact):* Phone #:* ( ) - 3. Enrollment/Eligibility Contact check if same as Primary Contact (#2) ( *required if batch selected): Phone #: ( ) - 4. Reporting Contact:* check if same as Primary Contact (#2) Phone #:* ( ) - Address: City: State: Zip Code: 5. Contribution Contact: check if same as Primary Contact (#2) ( *required if employer initiating contributions to an employee account) Phone #: ( ) - 6. Payroll Vendor/System Contact: check if same as Primary Contact (#2) Phone #: ( ) - 11 Additional Contacts: Contact Name: Contact Type: Phone #: ( ) - Contact Name: Contact Type: Phone #: ( ) - Page 2 of R4

9 Definitions of Data Requested: Health Savings Account Employer Set-up Bank Notification Base Medical Policy # (Group ID) Employer group ID 1. Employer Information: Employer Name Name of Employer Employer Address 1 Employer s street address (1) Employer Address 2 Employer s street address (2), if applicable City Employer s city State Employer s state Zip Employer s zip Payer/ TPA Name Insurer offering the High Deductible Health Plan Broker Agency Name Name of Broker Agency Broker Agency Tax ID # Broker Agency Tax Identification Number Broker Agency Address Broker Agency address Broker Agency Contact Name Name of contact at Broker Agency Broker Agency Phone# Phone number of Broker Agency Broker Agency Fax # Fax number of Broker Agency Broker Agency address of Broker Agency Broker Name Name of Broker Broker ID/License # Broker s ID or License number Broker Address Broker s address Broker Phone # Broker s phone number Broker Fax # Broker s fax number Broker Broker s address 2. Policy Information Effective date of High Deductible Health Plan Date High Deductible Health Plan is effective Case Sold Date Date the High Deductible Health Plan was sold to the employer group Projected Number of HSA accounts Estimated number of HSA Accounts this group will have based on membership As of date: Date associated to the projected number of HSA accounts provided 3. Enrollment Information: Enrollment Method Method employer would like to enroll employees: Online = Employee will enroll in their OptumHealthBank HSA account through OptumHealthBank s online enrollment tool found at Paper = Send PDF of all enrollment materials to HSA Primary Contact - Employee will complete, sign, and mail OptumHealthBank's HSA paper application. OptumHealthBank to employer a PDF file of the enrollment kit. Paper = Send enrollment kits to HSA Primary Contact - Employee will complete, sign, and mail OptumHealthBank's HSA paper application. OptumHealthBank to mail employer requested number of enrollment kits. HSA Batch File = Batch (With Affirmation) - Employer FTPs OptumHealthBank an electronic eligibility batch enrollment file based on a defined frequency. Standard file format to be provided during implementation. Employer provides OptumHealthBank HSA Terms and Conditions, captures employees' HSA affirmation, and includes affirmation on OptumHealthBank standard batch file. A confirmation of application will be mailed to the employee requesting a signature. The employee cannot access their funds until the signature is received. Batch (Without Affirmation) - Employer FTPs OptumHealthBank an electronic eligibility batch enrollment file based on a defined frequency. Standard file format to be provided during implementation. A confirmation of application will be mailed to the employee requesting a signature. The account will not be opened (and contributions will not be accepted) until the signature is received Enrollment Year Year enrolling in HSA Open Enrollment Meeting Date Date on which employer s open enrollment meetings will be held. If more than one date indicate first one Open enrollment period from Date of employer s open enrollment period Open enrollment HSA phone number Employer s open enrollment HSA phone number (toll-free) Is the employer contract signed? Question asking if we have an Employer Agreement for HSA Affirmation 4. Will Payroll Deductions be Transferred into the Employee s HSA Account? Question asking if contributions will be made via payroll deduction 5. Will Employer be Contributing to Employee s HSA Account? Question asking if the employer will be contributing to employee s HSA Page 3 of R4

10 6. Contribution Method ACH Direct Deposit via payroll Combined Sum ACH Wire Check Health Savings Account Employer Set-up Bank Notification Automated Clearing House network transaction. This is a reliable and efficient nationwide batchoriented electronic funds transfer system governed by NACHA OPERATING RULES which provide for the interbank clearing of electronic payments for participating depository financial institutions. The Federal Reserve and Electronic Payments Network act as ACH Operators, central-clearing facilities through which financial institutions transmit or receive ACH entries. Content and format for each of these components is very specific and must follow predefined formats to be valid. SEE OPTUMHEALTHBANK CONTRIBUTION ADMISTRATIVE GUIDE FOR THE HSA PRODUCT FOR DETAILS. Electronic Combined Sum ACH contributions to an HSA account is a simple, two-part process. The first step consists of sending an electronic contribution file detailing the specific employee accounts and the dollar amounts that are to be deposited. The second step is to send an ACH to OptumHealthBank for the total amount. Content and format for each of these components is very specific and must follow predefined formats to be valid. SEE OPTUMHEALTHBANK CONTRIBUTION ADMISTRATIVE GUIDE FOR THE HSA PRODUCT FOR DETAILS. Electronic wire contributions to an HSA account is a simple, two-part process. The first step consists of sending an electronic contribution file detailing the specific employee accounts and the dollar amounts that are to be deposited. The second step is to send an electronic funds wire to OptumHealthBank for the total amount. Content and format for each of these components is very specific and must follow predefined formats to be valid. SEE OPTUMHEALTHBANK CONTRIBUTION ADMISTRATIVE GUIDE FOR THE HSA PRODUCT FOR DETAILS. Contributions may be made by either the employer or the account holder (i.e., employee) via a manual check that is submitted with worksheet detailing the contribution. This contribution method is for employers with less than 100 employees or Account Holders. SEE OPTUMHEALTHBANK CONTRIBUTION ADMISTRATIVE GUIDE FOR THE HSA PRODUCT FOR DETAILS. 7. Contribution Frequency: Frequency by which contributions will be made to employee accounts. Selections are weekly, semimonthly, monthly and other. 8. Will Employer Want to Receive a Listing of Employee Account Question asking if employer wants to receive listing of account Numbers? numbers. Account Number File Recipient Name a. Name of employer contact who would like to receive a listing of account numbers for their employees who have an open HSA account. The account numbers will be needed by the employer when making contributions. Phone Phone number of employer contact receiving account number file address of employer contact receiving account number file Frequency Frequency of the account number file. Selections are weekly, bi-weekly, monthly and other 9. Approved PRP Requests Is a PRP request associated to Employer Question asking if there is an approved PRP associated with this Employer Group. Group? PRP # PRP number Brief Description Brief description of PRP Comments Section for comments 10. Contact Information: Form Submitter Name of person filling in form Phone Phone number of person filling in form address of person filling in form Primary Contact Employer s Human Resources contact for HSA Account Phone Phone number of employer s Human Resources contact for HSA Account address of employer s Human Resources contact for HSA Account Enrollment/Eligibility Contact Employer s Enrollment/Eligibility contact Phone Phone number of employer s Enrollment/Eligibility contact address of employer s Enrollment/Eligibility contact Reporting Contact Employer s contact for reports Phone Phone number of employer s contact for reports address of employer s contact for reports Contribution Contact Employer s contact for contributions Phone Phone number of employer s contact for contributions address of Employer s contact for contributions Payroll Vendor/System Contact Employer s contact for payroll (this could be a vendor) Phone Phone number of employer s contact for payroll (this could be a vendor) address of employer s contact for payroll (this could be a vendor) 11. Additional Contacts Contact Name Name of additional contact for HSA Account Contact Type Contact Type of additional contact for HSA Account (reports, contributions, account number file, etc.) Phone Phone number of additional contact for HSA Account address of additional contact for HSA Account Page 4 of R4

11 Bank OptumHealthBank.com Toll-free phone: H E A LT H S AV I N G S A C C O U N T ( H S A ) A P P L I C A T I O N To avoid processing delays, please complete all fields on the application starred fields (*) are required. Mail your completed application (and opening deposit, if applicable) to: OptumHealth Bank, P.O. Box 30777, Salt Lake City, UT Or fax both sides of this form to: and mail opening deposit, if applicable, separately to: OptumHealth Bank, P.O. Box , Salt Lake City, UT PART 1: PERSONAL INFORMATION ACCOUNT HOLDER * Social Security # / * Date of Birth Tax Identification # (mm/dd/yyyy) / / * First Name Middle I nitial * Last Name * Street Address (cannot be a.p.o box) Apt # * City * State * ZIP Mailing Address (if different than street address) Apt # City State ZIP * Home phone # ( ) ) * Verification Code (such as your Mother s Maiden Name) To be Used for Security Purposes Up to 10 Letters Work phone # ( ext. Address PART 2: REQUEST FOR ADDITIONAL DEBIT CARD (OPTIONAL) You will receive a Health Savings Account MasterCard Prepaid Debit Card. If you wish to request a Health Savings Account Card authorized user either your spouse or another eligible dependent please complete the section below. SM for use by an Authorized U ser s First Name Middle Initial Date of Birth Social Security # / (mm/dd/yyyy) Tax Identification # If Address is Same as Account Holder, check here / / Mailing Address City Last Name State ZIP PART 3: HIGH-DEDUCTIBLE HEALTH PLAN (HDHP)/MEDICAL PLAN INFORMATION * Medical Insurance Company or Carrier * Medi cal Insurance Plan or Group # HDHP Member Identification # (you may find this on your ID card) *Who is Covered? (check one): Individual Family [Individual + Dependent(s)] * HDHP Effective Date / / *Are you Enrolling in an HSA through your Employer? (check one): Yes No If Yes, Provide your Employer s Name: /07 PLEASE TURN PAGE OVER AND COMPLETE BOTH SIDES OF THIS APPLICATION >

12 PER THE USA PATRIOT ACT: To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account. When you open the account, we will ask for your name, street address, date of birth and other information that will allow us to identify you. We may also ask to see your driver s license or other identifying documents. Form of Identification (check one): Driver s License State ID Passport Identification # State of Issuance PART 4: BENEFICIARY INFORMATION (OPTIONAL) If you do not designate otherwise, your estate will be the beneficiary of your HSA upon your death. To designate an alternative beneficiary, please complete a Designation of Beneficiary form, available on OptumHealthBank.com or request one from customer service at PART 5: REQUIRED SIGNATURE (Please Read Before Signing) By signing below, I acknowledge that: I wish to establish an HSA with OptumHealth Bank as custodian. I understand and agree that my HSA will be opened under and governed by OptumHealth Bank s Custodial and Deposit Agreement. Terms of this agreement will be binding on me unless I close my account within 30 days. This document will be sent to me when my account is opened, along with OptumHealth Bank s Privacy Policy and Schedule of Fees. I authorize OptumHealth Bank to provide information about my HSA, including my account number, to my employer (if applicable) and those acting on behalf of my employer or OptumHealth Bank (if applicable), in connection with the establishment and maintenance of my HSA. I acknowledge that my employer and all others acting on behalf of my employer (if applicable), may provide information on my behalf to establish and maintain my HSA. I understand my monthly account statements will be made available to me electronically. I agree to notify OptumHealth Bank if I wish to have statements mailed to my home address. If I have filled out the information to request an additional debit card, I hereby request OptumHealth Bank to issue a debit card on my account to the person indicated and I acknowledge I will be liable for the use of the debit card by the Authorized User. I certify that the information provided in this application is true and complete. X * Account Holder Signature Required IMPORTANT: We cannot process this application without your signature. Date PART 6: OPENING DEPOSIT Opening deposit enclosed with application (if applicable) (check one): Yes No Amount: $ If you are an individual mailing an opening deposit for your own HSA, please write your name and social security number on the check. page 2

13 Page 1 DECLARATION OF DOMESTIC PARTNERSHIP I. DECLARATION: We, and, each (Employee - Print Name) (Domestic Partner - Print Name) Certify and declare that we are domestic partners in accordance with the following criteria: II. STATUS: 1. We affirm that this domestic partnership began on or about / /. 2. We are each other's sole domestic partner, and we intend to remain so indefinitely. 3. Neither of us is married to or legally separated from anyone else nor have had another domestic partner within the prior twelve (12) months. 4. We are both at least eighteen (18) years of age and mentally competent to consent to contract. 5. We are not related by blood to a degree of closeness that would prohibit legal marriage in the state in which we legally reside. 6. We cohabit and reside together in the same residence and intend to do so indefinitely. We have resided in the same household for at least six months. 7. We are engaged in a committed relationship of mutual caring and support and are jointly responsible for our common welfare and living expenses. Our interdependence is demonstrated by providing Oxford Health Plans at least three of the following (please check appropriate items): Common ownership of real property (joint deed or mortgage agreement) or a common leasehold interest in property Common ownership of a motor vehicle Driver's license listing a common address Proof of joint bank accounts or credit accounts

14 Page 2 Proof of designation as the primary beneficiary for life insurance or retirement benefits, or primary beneficiary designation under a partner's will Assignment of a durable property power of attorney or health care power of attorney 8. We are not in this relationship solely for the purpose of benefits coverage. 9. In those jurisdictions that permit filing for Domestic Partnership with applicable state or municipal agencies, applicants must show proof of compliance with the procedure. III. DEPENDENT CHILDREN OF DOMESTIC PARTNER: We understand that dependent children of (Domestic Partner - Print Name) are eligible for coverage when they are: - unmarried, - primarily dependent on the employee for support, - living with the employee in a regular parent-child relationship, and - meet the age/school requirements of the plan of benefits. IV. CHANGE IN DOMESTIC PARTNERSHIP: 1. We have an obligation to notify Oxford Health Plans by filing a Declaration of Termination of Domestic Partnership if there is any change in our domestic partnership status as attested to in this Declaration that would terminate this Declaration (e.g., due to death of a partner, a change in residence of one partner, termination of the relationship, etc.). We will notify Oxford Health Plans within thirty-one (31) days of such change. 2. We understand that termination of this coverage (obtained as a result of completion of this Declaration) will be effective on the date the relationship ends as indicated on the Declaration of Termination of Domestic Partnership, providing coverage has not otherwise terminated due to standard policy provisions.

15 Page 3 V. ACKNOWLEDGEMENTS: 1. We understand that a civil action may be brought against one or both of us for any losses (as well as attorney's fees and costs) due to any false statement contained in this Declaration or for failure to notify Oxford Health Plans of changed circumstances as required in Section IV above. I, the undersigned employee, further understand that falsification of information in this Declaration, or failure to notify Oxford Health Plans of changed circumstances pursuant to Section IV above may lead to disciplinary action against me, including discharge from employment. 2. We have provided the information in this Declaration for use by Oxford Health Plans for the sole purpose of determining our eligibility for certain domestic partner benefits. We understand and agree that Oxford Health Plans is not legally required to extend any such benefits. 3. We understand that this Declaration may have legal implications relating, for example, to our ownership of property or to taxability of benefits provided, and that before signing this Declaration, we should seek competent legal advice concerning such matters. We affirm, under penalty of perjury, that the statements in this Declaration are true and correct. / / / / Employee's Signature Date of Birth Today's Date / / / / Domestic Partner's Signature Date of Birth Today's Date Employee and Domestic Partner Address: City State Zip Code Sworn to before this day of,. Notary Public

16 Sole Proprietor and Group of One Attestation Form I. Business Organization Information: a. Name of Organization: Tax ID # or SS #: Primary Business Activity: Address: City: State: Zip: b. Contact Information for Business Organization Name: Fax: Title: Phone Number: II. Sole Proprietor Attestation: By executing this document, I hereby attest that: (i) the above described business organization is not an association, group purchasing organization or employee leasing organization and was formed for a lawful business purpose and not for the primary purpose of obtaining group insurance; (ii) I am the owner and operator of the above described business organization; (iii) I work a minimum of twenty (20) hours per week for this business organization; I derive the majority of my earned income (non-passive or non-investment) from the income generated from the above business organization; (iv) I seek health coverage only for myself and my eligible dependents through the above described business; (v) I (and my eligible dependents) am the only person eligible for health coverage through the above described business organization; (vi) I will promptly advise Oxford in the event that any of the statements made in this Attestation are no longer accurate. III. S-Corporations with One Eligible Employee Attestation: By executing this document, I hereby attest that: (i) the above described business organization is not an association, group purchasing organization or employee leasing organization and was formed for a lawful purpose and not for the primary purpose of obtaining group insurance; (ii) I am the sole shareholder of the above described business organization; (iii) I am currently employed by the above described business organization and work a minimum of twenty (20) hours per week for the business organization; (iv) I derive the majority of my earned income (non-passive or non-investment) from services provided to the above business organization; (v) I seek health coverage only for myself and my eligible dependents as listed on my enrollment form; (vi) I (and my eligible dependents) am the only person eligible for health coverage through the above described business organization; and (vi) I will promptly advise Oxford in the event that any of the statements made in this Attestation form are no longer accurate. IV. Tax Forms and other Documents (applicable to both Sole Proprietors and S-Corporations): By executing below, I agree to provide upon request appropriate tax forms to Oxford to validate the eligibility status. Before application will be considered, the applicant must execute this Attestation Form and provide the tax information and related documents indicated on the attached correspondence. Oxford reserves the right to modify these documentation and eligibility requirements in the future. NY

17 Sole Proprietor and Group of One Attestation Form The undersigned certifies that, to the best of his or her knowledge and belief, and under penalty of perjury, the information listed above is true and complete. X. Signature of Applicant Date Oxford insurance products are underwritten by Oxford Health Insurance, Inc. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation. NY

18 New York Health Benefits Waiver of Coverage Local Address: 48 Monroe Turnpike, Trumbull, CT Group Name: Policyholder Name: Employee Name: Last First Middle Initial Marital Status: Single Married Widowed Divorced Date of Employment: Date of Birth: I was given the opportunity to enroll in this plan of group health benefits offered by my employer and insured by Oxford Health Plans (NY), Inc. and/or Oxford Health Insurance, Inc. and I refuse coverage. Reason for Refusal (Please check all appropriate boxes.) other group coverage sponsored by my employer other group coverage sponsored by my spouse s employer other group coverage sponsored by another organization other reasons (please explain) Please provide name of carrier and policy number: Signature of Employee Date Benefits Administrator Signature Date NY Rev 2