Employer Application (MetLife Dental, VSP, Unum Life/LTD, & Landmark Chiro/Acu)

Transcription

1 Employer Application (MetLife Dental, VSP, Unum Life/LTD, & Landmark Chiro/Acu) To allow sufficient processing time, all MetLife submission materials need to be submitted prior to the requested effective date. If the insurance is currently in-force, please do not cancel coverage until receipt of risk acceptance letter from MetLife. Group Information - CoPower communication is by electronic mail Company Name: Contact Name: If you wish to opt out of communication, check this box and provide mailing address below. Street Address: City: State: Zip: HR360 Enrollment (Free Online HR Support): Yes No Total # of Employees: Total # of Eligible Employees: Group COBRA Status: Cal-COBRA Fed-COBRA Employed 2-19 (Cal-COBRA) or 20+ (Fed-COBRA) eligible employees on at least 50% of its working days in the previous calendar year Domestic Partners allowed to enroll? Yes No Children of Domestic Partners eligible to enroll? Yes No MetLife Dental (2-99) (Enter contribution amount on page 5) Prior Carrier: None Cancel Date: Total # of Enrolling Employees: MetLife Plan Selection (Dual Choice available for groups of 10+): Classic MAC $1500 Classic $1500 Classic $1500 Vol (5+) Preferred $1500 Preferred $1500 w/ortho (5+) Preferred $1500 w/ortho Vol (5+) Preferred $1500 Vol (5+) Elite $1500 Elite $2000 (10+) Elite $2000 w/ortho (10+) Additional Coverage Options In addition to the MetLife Dental plan, you may sign up for VSP, Unum, and Landmark s plans using the section below. Vision Service Plan (2-1000) Prior Carrier: None Cancel Date: Total # of Enrolling Employees: Employer Contribution: Employee: (100% for all plans except the voluntary plans) Dependent: (minimum 0%) Choice Plan A $20 Choice Plan B $25 Choice Plan B $25 ($130) Choice Plan B $20/$20 Vol Choice Plan B $10/$25 Vol Choice Plan C $25 Choice Plan C $25 ($130) Choice Plan C $25 Vol Choice Plan C $20/$20 Vol Choice Plan C $10/$25 Vol Signature Plan B $25 Unum Life/AD&D (2-249) and LTD (10-249) Basic Life and AD&D Voluntary Life & AD&D Unum LTD Prior Carrier: None Prior Carrier: None Prior Carrier: None Cancel Date: Cancel Date: Cancel Date: Total # of Enrolling Employees: Total # of Enrolling Employees: Total # of Enrolling Employees: Available to all groups Only for groups with 10+ Enrolled Employees Voluntary Life: Supplemental (2+ enrolling) Standalone (10+ enrolling) Select Elimination Period: 90 day 180 day 360 day $10,000 $15,000 $20,000 $25,000 $50,000 $100,000 $150,000 Each member or spouse applying must submit the Unum Voluntary Life Application. A completed Evidence of Insurability Form is only required for amounts over Guaranteed Issue. Please sign the Basic Term Life Applications on page 14. If enrolling in Voluntary Life & AD&D, check the Group Lifestyle Protection Accidental Death & Dismemberment Benefits box. Healthcare Protect Rider: Yes No If Yes, choose benefit: $300 $500 $1,000 Please complete and sign the Application for Group Insurance - LTD on page 15. Class Schedule: (3 employee min. per class; Further class specifications may be provided on separate sheet) Schedule A: Same coverage for all Job Classifications Schedule B: Coverage Differs by Job Classification Class 1: Class 2: Class 3: Landmark Chiropractic & Acupuncture (2-199) Enrollee must be enrolled in group medical to qualify Total Number of Enrolling Employees: Employer Contribution Employee: (minimum 50%) Dependent: (minimum 0%) Medical Carve-out? (Minimum 5 Enrolled) If yes, choose one: HMO PPO Plan Type: Chiro Only Chiro + Acu Product Category: Standard Expanded Office Copay: $10 (51+ EE only) $15 $20 Visits: (51+ EE only)

2 Administrative Fee Policy Charged monthly $10 Unum Life, & Unum LTD $15 VSP (2-4 Groups receive a 1 year discounted rate of $10) $15 Any combination of VSP, Unum Life, & Unum LTD No fees applicable MetLife Dental and Landmark Chiro/Acu Payment/Invoice - CoPower communication is by electronic mail Invoices If you wish to opt out of invoices, check this box Contact Name address The above information will be used to authenticate access to the invoice. You must notify CoPower if this contact or address changes. Initial Payment Do you wish to have your initial payment debited from your company account? Yes Please complete the bank information below, enter the premium amount and attach a copy of a voided check. No Please submit a company check made payable to CoPower. Ongoing Payment Do you wish to have your monthly invoice amount automatically debited from your company account? Yes Please complete the bank information below and attach a copy of a voided check. (Allow up to one billing cycle to process your request. You must continue to submit your payment until your invoice indicates that the amount due will be debited from your account.) No Bank Account Information (must be a Checking Account) Account Holder s Name (if different from above): Name of Bank: Bank Address: Bank Routing Number: Account Number: Premium Amount Number (e.g. $50): $ Premium Amount Written (e.g. fifty dollars) I hereby authorize CoPower to initiate debits from the account identified above. I understand it remains in effect until I give written notice to CoPower, which I must do by the 25 th of the month. If I want to change the banking information that CoPower debits, I will submit a new Direct Debit Authorization form by the 25 th of the month. In the event a debit is made to my account in error, I authorize CoPower to make a correcting entry to my account. CoPower will notify me of payments returned for insufficient funds or close accounts, and repayment instructions. Employer Signature My signature on this document certifies that all of the information contained in this application is true and correct to the best of my knowledge. I confirm that all enrollees are eligible employees, COBRA participants, and/or their dependents. In addition, my group complies with all the rules and regulations as set forth by the applicable carrier(s). Signature of Company Officer: Name (print): Date: Title (print): dollars Producer Statement (Must be completed for commissions. Producers (agent or agency) must have a signed Producer Agreement with CoPower.) Producer s Signature: Producer s Name (print): Federal Tax ID or SSN: Company Name: Address: City: Producer s Signature: Producer s Name (print): Federal Tax ID or SSN: Company Name: Address: State: Zip: Date: State: Zip: Date: Telephone: Fax: Telephone: Fax: City: Make commissions payable to: Producer Agency Make commissions payable to: Producer Agency Multiple producer split: Yes No Percentage of split: % Multiple producer split: Yes No Percentage of split: % The following is a list of items necessary to complete the implementation process: New Group Submission Application (First page must be typed) Signed rates on HealthConnect quote. Completed Employee enrollment (choose one): CoPower SELECT Census Enrollment form CoPower Employee Enrollment/Change Form All Plans (To be completed by each enrolling employee) Proof of employment for eligible employees age 70 and over, which can be submitted as W2/Wage Report or letter on company letterhead Submit a company check made payable to CoPower or completed Direct Debit information above For PPO: Employer Participation Agreement Non-MetLife Plans: DE-9C or Payroll Register only required if enrolling Unum or non-voluntary VSP groups with 10 or less enrolled employees Unum forms only required if enrolling in Unum Life or LTD plans Copy of current medical bill only required if enrolling for Landmark CPF /17

3 PAGE 3 CUSTOMER INFORMATION Legal Name of Company: Legal Address of Company (No PO Boxes): Address Line 2: City, State, Zip: Employer Tax Identification Number (TIN): SIC Code used to Rate Group: Effective Date: Year Company Founded: Broker Due Date: Next Business Day Number of eligible employees: Coverage(s) sold: n PPO Dental n DHMO Does this group have existing coverage with MetLife? If yes, please include the group #: BROKER INFORMATION Broker First and Last Name: Social Security #: Corporation Name: Federal Tax ID: Resident State: Broker Address 1: Broker Address 2: Broker City, State, Zip: Broker Contact Name: Phone: Is Broker Appointed with MetLife? n Yes n No If no or unsure, please contact your MetLife Implementation team. Commissions Paid to: n Writing Producer n Brokerage GENERAL AGENCY INFORMATION General Agency Name (must be different than corporation name above): General Agency Writing Producer s Name (must be different than Broker s name above): General Agency Writing Producer's Social Security #: GA Sales Office: 1 General Agency Contact Name: Phone: 1 For GA s with multiple locations, please specify which GA sales office/location is attached to this sold case

4 PAGE 4 TPA INFORMATION (IF APPLICABLE) TPA Name : TPA Writing Producer First and Last Name: TPA Writing Producer's Social Security #: TPA Sales Office: 2 TPA Contact Name: Phone: 2 For TPA's with multiple locations, please specify which TPA sales office/location is attached to this sold case PRIMARY CONTACT/BENEFIT ADMINISTRATOR INFORMATION Contact First and Last Name: Billing Address Line 1 (if different than legal address above): Billing Address Line 2: City, State, Zip: Contact Contact Phone: Should this contact have access to: MetLink n Yes n No Do you wish for your GA/Broker to have MetLink access to your account? n Yes n No CUSTOMER EXECUTIVE CONTACT INFORMATION n Same as Above Contact First and Last Name: Contact Contact Phone/Fax: Should this contact have access to MetLink : n Yes n No MetLink Our Online administration system designed to make benefits administration easier. MetLink provides convenient, real-time access to MetLife s systems enabling you to efficiently add or modify employees employee information and look up dental or disability claim status. You can also view your current bill on-line, looking up billing history and run a listing of employees that can be reviewed on-line or downloaded into a spreadsheet. ELIGIBILITY INFORMATION Class Description: All Active Full Time Employees Number of hours worked: 30 hours EMPLOYEE WAITING PERIODS For Present Employees: days/months n Date Eligible n First of the Month For Future Employees: days/months n Date Eligible n First of the Month If you have additional classes or if class description or number of hours worked differs from above, please provide the eligibility information mentioned above for each class in the space provided below (multiple classes must be quoted by MetLife Underwriting). Domestic Partners: If your state does not require domestic partner and you would like it removed, please check here. n Please Remove Domestic Partner

5 PAGE 5 PREMIUM CONTRIBUTIONS Employer Contribution Percentage If the employer pays 100% of the premium, all eligible employees must participate. EMPLOYERS CONTRIBUTION ON BEHALF OF: DENTAL PPO DENTAL DHMO Employee % % Dependent % % ERISA INFORMATION MetLife provides as a standard service for ERISA plans a document entitled ERISA Information that, together with your insurance certificate, can be used as your Summary Plan Description. This includes a grant of discretion to MetLife, as claims administrator. If you do not want MetLife to provide this ERISA Information please notify your broker so the appropriate modifications can be completed. Special Case Notes (FOR METLIFE INTERNAL USE ONLY): AUTHORIZATIONS MetLife will deliver the group insurance policy and certificates to the company via as Adobe pdf documents and confirms that it is able to save them as electronic records and print them (if requested) for distribution to individuals who become covered under the group insurance policy. HIPAA Information (Dental & Vision Only): n I am an authorized representative of the MetLife customer named above. By checking this box, I understand and confirm that no access will be given to employee s Protected Health Information (PHI). This section is to be completed by the individual authorized by the company to sign the Application for Group Insurance in order to confirm that the company has requested or undertaken with respect to the implementation of MetLife insurance and/or service program(s). Please read carefully and complete by checking all boxes that apply. n By checking this box and signing below, I certify that I received a copy of the Intermediary Compensation Notice (included below) n By checking this box and signing below, I certify that the Gramm-Leach-Bliley Privacy Notice (included with their document) has been distributed to all affected employees. Signature of Executive Contact or Benefit Administrator Date

6 Employer Participation Agreement To: U.S. Bank National Association, as Trustees of the MetLife Pennsylvania Multiple Employer Trust We, the employer named below, wish to participate in and obtain group insurance from Metropolitan Life Insurance Company ( MetLife ) providing benefits under and subject to the provisions of the group policy issued by MetLife to the U.S. Bank National Association, as Trustees of the MetLife Pennsylvania Multiple Employer Trust that provides the group insurance coverage selected below: Coverage Dental Insurance Employees Only Employees and Dependents We request that the group insurance indicated above become effective. Mo. Day Year We hereby agree to be bound by the terms, conditions and provisions of the group insurance arrangement, including the policy, certain provisions of which are summarized at the end of this Agreement. We understand that the insurance will not become effective until this Employer Participation Agreement is accepted by or on behalf of the U.S. Bank National Association, as Trustees of the MetLife Pennsylvania Multiple Employer Trust by MetLife for the insurance involved. No insurance for any person proposed for coverage will become effective until that person has applied for such insurance and such person s enrollment form has been approved by MetLife, if MetLife s approval of such person is required. If our coverage becomes effective, we shall be deemed a Participating Employer under the policy issued to the U.S. Bank National Association, as Trustees of the MetLife Pennsylvania Multiple Employer Trust. We further understand that, if the group insurance indicated above will replace existing coverage, the basis for the premium rate quoted by MetLife was the reliance placed by MetLife on the accuracy and completeness of the documentation substantiating the scope and level of the coverage previously in force and the rate we were previously paying. We agree that if, subsequent to the date the insurance indicated above becomes effective, such documentation shall be found to have been inaccurate or incomplete, MetLife may, retroactively to the effective date of coverage, adjust the rate for such insurance to the rate that would have been applicable if MetLife had known the true state of facts. Finally, we understand that the policy is subject to termination by the U.S. Bank National Association, as Trustees of the MetLife Pennsylvania Multiple Employer Trust. Date Name of Employer Signature & Title ============================================================================== Summary of certain terms, conditions and provisions of the Policy referred to above: (1) Definition of Participating Employer: The term Participating Employer means an employer that has executed an Employer Participation Agreement to insure its employees through the policy that is issued to the U.S. Bank National Association, as Trustees of the MetLife Pennsylvania Multiple Employer Trust. 6 of 15 Metropolitan Life Insurance Company New York, New York Printed in U.S.A. CoPower

7 (2) Definition of Employee: The term Employee means a person who is directly employed and compensated for services by a Participating Employer and who is in a class designated as eligible for insurance by that Participating Employer. No person may be considered an Employee of more than one Participating Employer, nor may any class of Employees be designated as eligible for insurance without the consent of MetLife. (3) MetLife s Responsibility: In return for a Participating Employer s payment of premiums when they fall due, MetLife will provide the insurance and pay the benefits described in the group insurance certificate furnished to that Participating Employer for delivery to the Participating Employer s covered Employees. (4) Premium Due Dates: Premiums are due and payable by each Participating Employer on the first day of each month for which insurance coverage for that Participating Employer is to be provided. The Participating Employer s first premium must be paid within 31 days of the effective date of the Participating Employer s coverage. If a premium payment, other than the Participating Employer s first premium payment, is not received within 31 days after the due date, coverage under the policy with respect to that Participating Employer will terminate on the earlier of the 31 st day following the due date and the date requested in writing by the Participating Employer, provided such request is made before such 30 th day following the due date. The Participating Employer will be liable for the payment of the premium which accrues while any coverage remains in force. (5) Change in Rates: MetLife may change any or all of the premium rates without prior notice if there is a change in the policy; when a class of eligible persons is added to or deleted from a Participating Employer s plan; when, with MetLife s consent, a Participating Employer s subsidiary, affiliate, divisions branch or other similar entity is added to or deleted from the policy; when there is a significant change in the geographic distribution of insured Employees; when applicable law requires a change in insurance or the class of persons eligible for insurance; or when a Participating Employer s premium due date coincides with or next follows: a change greater than 10% in the number of covered persons or a change greater than 10% in the amount of insurance. MetLife may change rates for any coverage at any time if data furnished to MetLife, and relied upon by MetLife as a basis for its rates, is found to be inaccurate or incomplete. (6) Information Needed and Policy Administration. All information necessary to compute Premiums and carry out the terms of this policy will be provided by the Policyholder and Participating Employer to MetLife. Such information: Will be provided in a timely manner and in a format as agreed to by MetLife and the Policyholder; Will be provided, maintained and administered as agreed to in Writing by MetLife and the Policyholder; and If maintained by the Policyholder, may be examined by MetLife at any reasonable time. If MetLife or the Policyholder or the Participating Employer makes a clerical error in keeping or providing the information, the Premium and/or benefits will be adjusted as warranted, according to the correct information. An error will not end insurance validly in effect, nor will it continue insurance validly ended or create insurance coverage where no coverage existed. Any act undertaken by the Policyholder or Participating Employer that relates to the insurance provided under this policy must be consistent with the terms of such insurance and with MetLife s requirements; including but not limited to the eligibility requirements of the Policyholder s plan or Participating Employer s plan as set forth in the certificates to this policy. (7) Termination: In addition to the termination provisions set forth above, MetLife will have the right to terminate the policy on any policy anniversary and the right to terminate the Participating Employer s plan: on a date premium is not paid when due; or on any premium due date upon 30 days notice if less than 25% of the eligible Employees are insured for contributory insurance; or fewer than 100% of the eligible Employees are insured for non-contributory insurance; or less than 25% of all eligible dependents are insured for contributory dependent insurance. MetLife may also terminate the Participating Employer s plan on any premium due date by giving 30 days notice if the Participating Employer fails to provide information on a timely basis or perform any obligations required by the policy or any applicable law; or on the date a Participating Employer ceases to satisfy the criteria for a Participating Employer as contained in the definition 7 of 15 Metropolitan Life Insurance Company New York, New York Printed in U.S.A. CoPower

8 of Participating Employer upon 30 days notice. The Participating Employer may end the plan by giving 30 days notice to MetLife or the U.S. Bank National Association, as Trustees of the MetLife Pennsylvania Multiple Employer Trust. The plan will end on the later of: the date stated in the notice or the date the notice is received. If a plan ends all premiums due for the plan must be paid. MetLife will refund any unearned premium. (8) Changes in the Policy: The policy may be changed at any time without the consent of the covered persons or anyone else with a beneficial interest in it. MetLife will issue amendments or endorsements to effect such changes. MetLife will only make changes that are consistent with applicable law. An amendment or endorsement will not affect the insurance provided under certificates issued before the effective date of the change, unless retroactivity is consistent with applicable law. An officer of MetLife must approve in writing any change or waiver of the terms and provisions of this policy. A sales representative or other MetLife employee, who is not an officer of MetLife, does not have MetLife s authority to approve such changes or waivers. A change or waiver will be evidenced by an amendment signed by an officer of MetLife, and the Policyholder or its designee. An endorsement will be signed by an officer of MetLife. A copy of the amendment or endorsement will be provided to the Policyholder for attachment to the policy. 8 of 15 Metropolitan Life Insurance Company New York, New York Printed in U.S.A. CoPower

9 INTERMEDIARY AND PRODUCER COMPENSATION NOTICE MetLife enters into arrangements concerning the sale, servicing and/or renewal of MetLife group insurance and certain other group-related products ( Products ) with brokers, agents, consultants, thirdparty administrators, general agents, associations, and other parties that may participate in the sale, servicing and/or renewal of such Products (each an Intermediary ). MetLife may pay your Intermediary compensation, which may include, among other things, base compensation, supplemental compensation and/or a service fee. MetLife may pay compensation for the sale, servicing and/or renewal of Products, or remit compensation to an Intermediary on your behalf. Your Intermediary may also be owned by, controlled by or affiliated with another person or party, which may also be an Intermediary and who may also perform marketing and/or administration services in connection with your Products and be paid compensation by MetLife. Base compensation, which may vary from case to case and may change if you renew your Products with MetLife, may be payable to your Intermediary as a percentage of premium or a fixed dollar amount. MetLife may also pay your Intermediary compensation that is based upon your Intermediary placing and/or retaining a certain volume of business (number of Products sold or dollar value of premium) with MetLife. In addition, supplemental compensation may be payable to your Intermediary. Under MetLife s current supplemental compensation plan, the amount payable as supplemental compensation may range from 0% to 8% of premium. The supplemental compensation percentage may be based on: (1) the number of Products sold through your Intermediary during a prior one-year period; (2) the amount of premium or fees with respect to Products sold through your Intermediary during a prior one-year period; (3) the persistency percentage of Products inforce through your Intermediary during a prior one-year period; (4) premium growth during a prior one-year period; (5) a fixed percentage of the premium for Products as set by MetLife. The supplemental compensation percentage will be set by MetLife prior to the beginning of each calendar year and it may not be changed until the following calendar year. As such, the supplemental compensation percentage may vary from year to year, but will not exceed 8% under the current supplemental compensation plan. The cost of supplemental compensation is not directly charged to the price of our Products except as an allocation of overhead expense, which is applied to all eligible group insurance products, whether or not supplemental compensation is paid in relation to a particular sale or renewal. As a result, your rates will not differ by whether or not your Intermediary receives supplemental compensation. If your Intermediary collects the premium from you in relation to your Products, your Intermediary may earn a return on such amounts. Additionally, MetLife may have a variety of other relationships with your Intermediary or its affiliates, or with other parties, that involve the payment of compensation and benefits that may or may not be related to your relationship with MetLife (e.g., insurance and employee benefits exchanges, enrollment firms and platforms, sales contests, consulting agreements, or reinsurance arrangements). More information about the eligibility criteria, limitations, payment calculations and other terms and conditions under MetLife s base compensation and supplemental compensation plans can be found on MetLife s Web site at Questions regarding Intermediary compensation can be directed to ask4met@metlifeservice.com, or if you would like to speak to someone about Intermediary compensation, please call (800) ASK 4MET. In addition to the compensation paid to an Intermediary, MetLife may also pay compensation to your MetLife sales representative. Compensation paid to your MetLife sales representative is for participating in the sale, servicing, and/or renewal of Products, and the compensation paid may vary based on a number of factors including the type of Product(s) and volume of business sold. If you are the person or entity to be charged under an insurance policy or annuity contract, you may request additional information about the compensation your MetLife sales representative expects to receive as a result of the sale or concerning compensation for any alternative quotes presented, by contacting your MetLife sales representative or calling (866) L [exp0917][All States] 9 of 15

10 CPN Group Initial Enr/SOH-2014 Our Privacy Notice We know that you buy our products and services because you trust us. This notice explains how we protect your privacy and treat your personal information. It applies to current and former customers. Personal information as used here means anything we know about you personally. Plan Sponsors and Group Insurance Contract Holders This privacy notice is for individuals who apply for or obtain our products and services under an employee benefit plan, or group insurance or annuity contract. In this notice, you refers to these individuals. Protecting Your Information We take important steps to protect your personal information. We treat it as confidential. We tell our employees to take care in handling it. We limit access to those who need it to perform their jobs. Our outside service providers must also protect it, and use it only to meet our business needs. We also take steps to protect our systems from unauthorized access. We comply with all laws that apply to us. Collecting Your Information We typically collect your name, address, age, and other relevant information. We may also collect information about any business you have with us, our affiliates, or other companies. Our affiliates include life, car, and home insurers. They also include a bank, a legal plans company, and securities broker-dealers. In the future, we may also have affiliates in other businesses. How We Get Your Information We get your personal information mostly from you. We may also use outside sources to help ensure our records are correct and complete. These sources may include consumer reporting agencies, employers, other financial institutions, adult relatives, and others. These sources may give us reports or share what they know with others. We don t control the accuracy of information outside sources give us. If you want to make any changes to information we receive from others about you, you must contact those sources. We may ask for medical information. The Authorization that you sign when you request insurance permits these sources to tell us about you. We may also, at our expense: Ask for a medical exam Ask for blood and urine tests Ask health care providers to give us health data, including information about alcohol or drug abuse We may also ask a consumer reporting agency for a consumer report about you (or anyone else to be insured). Consumer reports may tell us about a lot of things, including information about: Reputation Driving record Finances Work and work history Hobbies and dangerous activities The information may be kept by the consumer reporting agency and later given to others as permitted by law. The agency will give you a copy of the report it provides to us, if you ask the agency and can provide adequate identification. If you write to us and we have asked for a consumer report about you, we will tell you so and give you the name, address and phone number of the consumer reporting agency. Another source of information is MIB Group, Inc. ( MIB ). It is a non-profit association of life insurance companies. We and our reinsurers may give MIB health or other information about you. If you apply for life or health coverage from another member of MIB, or claim benefits from another member company, MIB will give that company any information that it has about you. If you contact MIB, it will tell you what it knows about you. You have the right to ask MIB to correct its information about you. You may do so by writing to MIB, Inc., 50 Braintree Hill, Suite 400, Braintree, MA , by calling MIB at (866) (TTY (866) for the hearing impaired), or by contacting MIB at Using Your Information We collect your personal information to help us decide if you re eligible for our products or services. We may also need it to verify identities to help deter fraud, money laundering, or other crimes. How we use this information depends on what products and services you have or want from us. It also depends on what laws apply to those products and services. For example, we may also use your information to: administer your products and services process claims and other transactions 10 of 15

11 perform business research confirm or correct your information market new products to you help us run our business comply with applicable laws Sharing Your Information With Others We may share your personal information with others with your consent, by agreement, or as permitted or required by law. For example, we may share your information with businesses hired to carry out services for us. We may also share it with our affiliated or unaffiliated business partners through joint marketing agreements. In those situations, we share your information to jointly offer you products and services or have others offer you products and services we endorse or sponsor. Before sharing your information with any affiliate or joint marketing partner for their own marketing purposes, however, we will first notify you and give you an opportunity to opt out. Other reasons we may share your information include: doing what a court, law enforcement, or government agency requires us to do (for example, complying with search warrants or subpoenas) telling another company what we know about you if we are selling or merging any part of our business giving information to a governmental agency so it can decide if you are eligible for public benefits giving your information to someone with a legal interest in your assets (for example, a creditor with a lien on your account) giving your information to your health care provider having a peer review organization evaluate your information, if you have health coverage with us those listed in our Using Your Information section above HIPAA We will not share your health information with any other company even one of our affiliates for their own marketing purposes. The Health Insurance Portability and Accountability Act ( HIPAA ) protects your information if you request or purchase dental, vision, long-term care and/or medical insurance from us. HIPAA limits our ability to use and disclose the information that we obtain as a result of your request or purchase of insurance. Information about your rights under HIPAA will be provided to you with any dental, vision, long-term care or medical coverage issued to you. You may obtain a copy of our HIPAA Privacy Notice by visiting our website at For additional information about your rights under HIPAA; or to have a HIPAA Privacy Notice mailed to you, contact us at HIPAAprivacyAmericasUS@metlife.com, or call us at telephone number (212) Accessing and Correcting Your Information You may ask us for a copy of the personal information we have about you. Generally, we will provide it as long as it is reasonably retrievable and within our control. You must make your request in writing listing the account or policy numbers with the information you want to access. For legal reasons, we may not show you anything we learned as part of a claim or lawsuit, unless required by law. If you tell us that what we know about you is incorrect, we will review it. If we agree, we will update our records. Otherwise, you may dispute our findings in writing, and we will include your statement whenever we give your disputed information to anyone outside MetLife. Questions We want you to understand how we protect your privacy. If you have any questions about this notice, please contact us. When you write, include your name, address, and policy or account number. Send privacy questions to: MetLife Privacy Office P. O. Box 489 Warwick, RI privacy@metlife.com We may revise this privacy notice. If we make any material changes, we will notify you as required by law. We provide this privacy notice to you on behalf of these MetLife companies: Metropolitan Life Insurance Company MetLife Health Plans, Inc. MetLife Insurance Company of Connecticut General American Life Insurance Company SafeGuard Health Plans, Inc. SafeHealth Life Insurance Company CPN Group Initial Enr/SOH of 15

12 HIPAA INFORMATION FOR METLIFE GROUP DENTAL and/or VISION INSURANCE CUSTOMERS Dear Group Dental and/or Vision Customer : This letter relates to privacy requirements contained in federal regulations under the Health Insurance Portability and Accountability Act (HIPAA). To comply with HIPAA s privacy rules, MetLife U.S. Business has put in place procedures and requirements relating to disclosure of protected health information (PHI) to our insured group customers with dental and/or vision coverage. Under HIPAA s privacy rules, an employer s group health plan may not disclose individually identifiable information that is classified as protected health information (PHI) under HIPAA or permit an insurer to disclose PHI to the plan sponsor unless the plan sponsor (1) amends its plan documents to incorporate specified HIPAA privacy safeguards, and (2) signs a written certification to the group health plan stating that it has done so. For purposes of this letter, the term plan sponsor means the employer or other entity that establishes or maintains a group health plan (such as a dental or vision plan) on behalf of the eligible employees and dependents ( plan participants.) If as a plan sponsor, your company does not wish to have access to plan participants PHI, these requirements may not apply. Except as noted below, as standard procedure we cannot provide access to the Dental or Vision Claim Inquiry features of MetLink, nor will we be able to provide assistance on a dental or vision claim issue, whether requested in writing or through the Customer Call Centers, to our customers (or through brokers or TPAs on their behalf) without a written authorization from the Employee. For your information the following are examples of the ways in which a MetLife group dental and/or vision customer may receive PHI: Access to dental or vision claim status via the Claim Inquiry features of MetLink; Verbal and/or written communication to a MetLife representative asking for assistance with a claim issue on behalf of an Employee, including calls to our Dental or Vision customer call centers. If an insured group dental and/or vision customer, acting as the plan sponsor, must have access to PHI in any format for plan administration functions, then based on the HIPAA privacy requirements outlined above, such a customer will need to certify to MetLife, in advance of receiving PHI from MetLife, that its plan document has been amended to reflect HIPAA s privacy requirements. This requirement will apply whether PHI is received directly by such a customer or through its broker or TPA on its behalf. Customers will be able to make their certification with MetLife using either of the following methods: 1. by signing a HIPAA Plan Sponsor Certification Form and returning it to MetLife. Upon review by your legal counsel, the attached sample wording can be used to create your company s HIPAA Plan Sponsor Certification Form for use after amending the plan document. (Use of the Plan Sponsor Certification Form is the only option if the MetLife booklet certificate does not serve as your plan document or if your plan is not governed by ERISA), or 12 of 15

13 2. if you use a MetLife booklet certificate as your plan document, and after review of the attached specimen "Sample Dental and/or Vision Booklet Certificate/SPD HIPAA Language" by your legal counsel, complete the attached HIPAA Request Form indicating that MetLife include the HIPAA privacy language in your booklet certificate. Samples of the HIPAA Plan Sponsor Certification Form and new HIPAA privacy language are included for reference. Please note that the attached sample forms and language are only examples, and are not intended to constitute legal advice. We suggest you consult with your legal counsel concerning the status of your group health plan under HIPAA, HIPAA requirements in general, and on any proposed use of these sample forms or language. If for plan administration functions your organization must have access to your plan participants dental and/or vision claim status via MetLink, or receive information which contains PHI, please submit, either your completed HIPAA Plan Sponsor Certification Form or your HIPAA Request Form. You should know that if MetLife does not receive your certification in one of the above formats, we will not be in a position to disclose PHI to you, including permitting access to the Dental and/or Vision Claim Inquiry features of MetLink. MetLife U.S. Business is committed to keeping its customers informed on HIPAA issues. Should you require additional information, please do not hesitate to contact us. Thank you for your assistance in this matter. Sincerely, MetLife Attachments: Sample HIPAA Plan Sponsor Certification Form Sample Dental and/or Vision Booklet Certificate/SPD HIPAA Language HIPAA Request Form 13 of 15

14 Page 14 of 15 Basic Term Life

15 unum APPLICATION FOR GROUP INSURANCE Unum Life Insurance Company of America 2211 Congress Street Portland, Maine LTD Name of Applicant Address: (Street) (City) (State) (Zip) applies to the Unum Life Insurance Company of America, for: o Group Life Benefits O Group Cancer Benefits o Group Long Term Care Benefits o Group Accidental Death and Dismemberment Benefits o Group Critical Illness Benefits o Group Short Term Disability Benefits IJ Group Worksite Short Term Disability Benefits (:) Group Long Term Disability Benefits O Tax Qualified* O Non-Tax Qualified** o Nursing Home Insurance CJ Comprehensive Insurance o Group Accident Benefits Is there any group life insurance plan in force or being applied for on some or all employees? CJ Yes o No If yes, complete the following or list the prior carriers: Employee Class Maximum Amounts Name of Carrier Effective Dates (mmtddiyyyy) Termination Dates (mm/ddlyyyyl If the Insurance Company approves this application, a policy will be issued. The applicant agrees that acceptance of the policy will be an approval of the policy terms. The policy specifications will be made a part of the policy along with a copy of this form. Signed at (City and State) (Applicant) on (mm/dd/yyyy) By: (Signature and Title) Broker Name: CoPower Administrators, Inc. (Please Print) Broker Signature:'-:..- SS# I Tax ID# (last 4 digits): _2_3_4_9 Policy Effective Date: (mm/dd/yyyy) *The contract for Long-Term Care Insurance is intended to be a federally qualified Long-Term Care Insurance contract and may qualify for Federal and State tax benefits. **The contract for Long-Term Care Insurance is not intended to be a federally qualified Long-Term Care Insurance contract. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries. AE-1080-CA Page 15 of 15