Please complete in black ink only. Section A: Company Information Employer tax ID no. (required) City County State ZIP code. City State ZIP code

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1 Employer Enrollment Application For 1 50 Employee Small Groups 1 Nevada Please complete in black ink only. Section A: Company Information Company name Employer tax ID no. (required) Company street address City County State ZIP code Billing address If different from above City State ZIP code Organization type: Corporation Partnership Government unit/agency Limited Liability Company (LLC) Labor union trust Other: SIC code Required Type of business (be specific) Date business established Company contact name Title Primary phone no. Fax no. address Do you have any affiliates that qualify as a single employer under subsection (b), (c), (m) or (o) of Internal revenue Code Section 414? If yes, please give the legal names, federal tax ID no. and number of employees employed by each. Open Enrollment Our standard open enrollment period is at least 31 days before the Group s renewal date and 31 days after, which is held no more often than once in any 12 consecutive months. The Open Enrollment period does not apply to Life and Disability products. Section B: Application Type Requested effective date New enrollment (MM/DD/YYYY) 1 A small group must have at least one eligible employee, in addition to the business owner. A spouse cannot be the only eligible employee. SG_OHIX_NV_ER_R (1/17) Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Life and disability products underwritten by Anthem Life Insurance Company. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association NVEENABS 2017 OHIX MDV Employer App Prt FR NVEENABS Rev. 4/16 1 of 8

2 Section C: Type of Coverage 1. Medical Coverage Check all that apply. PPO Plans Anthem Gold Anthem Silver Anthem Bronze PPO (2HQZ) 500/20%/5000 (2HR7) 1000/20%/5000 (2HS0) 1500/0%/7150 (2HR8) 1500/30%/4500 (2HR2) 2000/20%/4000 (2HR9) 2000/40%/4000 Pathway PPO (2HRR) 500/20%/4000 (2HR5) 750/20%/4500 (2HR3) 1000/20%/4000/20 (2HQF) 1000/20%/4500 Choice (2HRV) 250/20%/4500 (2HRQ) 500/10%/6850 (2HRW) 750/20%/4500 (2HRN) 1000/10%/6000 (2HRX) 1500/20%/4000 (2HQJ) 1500/30%/7150 (2HRA) 1750/40%/7150 (2HR6) 2000/50%/6850 (2HRE) 2600/20%/4500 w/hsa (2HRZ) 3000/20%/7150 (2HRH) 4000/0%/4000 w/hsa (2HQM) 2000/30%/5500 (2HQK) 3000/30%/4500 (2HRS) 1500/40%/7150 (2HRT) 2000/40%/6300 (2HRL) 2500/25%/7150 (2HRU) 3000/40%/6850 HMO Plans Anthem Gold Anthem Silver Anthem Bronze Pathway HMO (2HQN) 1000/10%/5500 (2HQL) 1500/30%/5500 (2HQC) 4750/30%/7150 Choose your medical contribution for each month only one choice is allowed. (2HQG) 5900/0%/7150 (2HRB) 6000/20%/6550 w/hsa (2HRY) 6000/30%/7150 (2HRC) 6500/0%/6500 w/hsa (2HQV) 4500/50%/6550 w/hsa (2HQS) 5000/30%/7150 (2HQH) 5850/30%/7150 (2HQW) 6350/0%/6350 w/hsa (2HQR) 5000/30%/7150 Contribution option 1: Traditional option We will contribute (50% to 100%): % per employee % per dependent (optional). Contribution option 2: Percentage of plan option We will contribute (50% to 100%): % to plan. Contribution Option 3: Fixed-dollar option We will contribute (at least $125) $ per employee and $ per dependent (optional). For Health Savings Account (HSA) plans: Group will establish Health Savings Account (HSA) with Anthem facilitating with a banking services provider. Group will establish Health Savings Account (HSA) but does not want Anthem to facilitate in the creation of the account. Contract codes Indicate the contract codes for the medical plan(s) selected. Contract code: of 8

3 2. Dental Coverage Anthem Family Dental and Anthem Family Dental Enhanced plans include certified pediatric dental essential health benefits. All other plans including Anthem Dental Prime and Complete with product families including Value, Classic, Enhanced, and Voluntary do not include certified pediatric dental essential health benefits. Please list below the contract code for the dental plan(s) you select. Contract codes Indicate the contract code(s) for the dental plan(s) selected. The codes can be found on the proposal/quote output. Contract code 1: Contract code 2: No dental coverage selected Choose your dental contribution for each month: % per employee % per dependent (optional) Select premium level: (Subject to underwriting approval) Base premium Bundled premium Medical Lock premium Medical Lock and Bundled premium Is this plan intended to replace any existing group dental coverage? If yes, please complete the information below for each group dental insurance plan you now have. Insurer Type of plan (DHMO, PPO) Effective date Proposed termination date Participation Requirements Voluntary participation 5 50 Eligible Employees: A minimum of five employees must enroll (there is no participation-percentage requirement for our voluntary plans). Dual Option is not available for voluntary plans. Value, Classic and Enhanced participation 2 4 Eligible Employees: 100% of eligible employees not covered by another dental plan minimum of two must enroll Eligible Employees: A minimum of 75% of employees not covered by another dental plan are required to enroll. A minimum of two must enroll. For orthodontia, a minimum of five employees must enroll. Dual Option (employer can select two plans to offer to employees) is available for groups with at least 15 net eligible employees. A minimum of five employees must enroll in each of the two options and the two plans offered must have a 20% premium differential. Medical Lock (Packaged Enrollment): Enrollment and tiering must be identical on both the Anthem medical and Anthem dental plans. Example: enrollees with Single medical coverage must also have Single dental coverage; enrollees with Family medical coverage must also have Family dental coverage. 3. Vision Coverage You may choose a maximum of two plans. No vision coverage at this time. Employer-Sponsored Plans (available for groups with 2 50 employees, minimum of two subscribers must enroll). Voluntary Plans (available for groups with 5 50 employees, minimum of five subscribers must enroll). Contract codes Indicate the contract code(s) for the vision plan(s) selected. The codes can be found on the proposal/quote output. Contract code 1: Contract code 2: Choose your vision contribution for each month. Your contribution must be the same for all plans. Employer-sponsored plans require employers to contribute between 50% and 100%. For Voluntary plans employers may contribute between 0% and 49%. We will contribute: % per employee % per dependent (optional) Select premium level: (Subject to underwriting approval) Base premium Bundled premium Medical Lock premium Medical Lock and Bundled premium Participation Requirements Medical Lock (Packaged Enrollment): All members enrolled in an Anthem medical plan must enroll in Anthem vision. Tiering must be identical on the medical and vision plans. Example: enrollees with Single medical coverage must also have Single vision coverage; enrollees with Family medical coverage must also have Family vision coverage. 3 of 8

4 4. Life and Disability Coverage Check all that apply. A minimum of two employees must enroll. Life products Disability products Select Life products and group contribution percentage: Select Disability products and group contribution percentage: Product choice Percentage Product choice Percentage None Basic Life & AD&D None Short Term Disability Basic Dependent Life Long Term Disability Optional Supplemental/Voluntary Life and AD&D* Voluntary Short Term Disability* Optional Supplemental/Voluntary Dependent Life* Voluntary Long Term Disability* *Available for Groups of 10+ *Available for Groups of 10+ Life and/or Disability Probationary Period/Waiting Period Would you like to waive the probationary period/eligibility waiting period for ALL existing employees at initial group enrollment? Is the eligibility waiting period for new eligible employees enrolling in Life and/or Disability plans after the group s coverage effective date the same as the Anthem medical policy eligibility period? If no, enter the Life and Disability eligibility probationary period below. Class number Coverage description (Ex. Life, Short Term Disability, Long Term Disability, etc.) Description of eligibility probationary period (Ex. Date of hire, First of month following 60 days of continuous employment, etc.) Eligible employees must be actively at work, and must satisfy any applicable waiting period. Minimum work hours required for eligible employees is 30 hours per week unless otherwise indicated. Prior Coverage Has this group had life and disability coverage within 30 days of this application s signature date? Will this plan replace current If yes, carrier name Termination date Life coverage Disability coverage Participation Requirements Basic Life, Basic Accidental Death & Dismemberment, Short Term Disability: 100% participation required on non-contributory plans and 75% participation required on contributory plans. Long Term Disability: 100% participation required on all non-contributory plans. 100% participation required for contributory plans of two or three eligible employees. 75% participation required on contributory plans with four or more eligible employees. Basic Dependent Life: 100% participation required on non-contributory plans. Optional/Voluntary Life/Accidental Death & Dismemberment: The greater of five enrolled employees or 20% participation required. Voluntary Short Term Disability and Voluntary Long Term Disability: The greater of 10 enrolled employees or 20% participation required. 4 of 8

5 Section D: Eligibility* 1. Total number of employees (including employed owners/officers): 2. Number of eligible full-time employees (minimum 30 hours per week): 3. Number of employees enrolling in: Medical: Vision: Dental: Life/Disability: 4. Number of eligible DECLINING employees: 5. Number of INELIGIBLE employees: 6. Number of employees working outside of NV: 7. Will coverage be restricted to a certain classification of employees? If yes, please explain what class(es): 8. Probationary period/waiting period for new employees/rehires for Medical/Dental/Vision: First of month after hire date 1 month 2 months The standard effective date is first of the month following the waiting period/probationary period. Would you like to offer the probationary/waiting period by class? If yes, please explain classes: Class 1: Waiting period: Class 2: Waiting period: 9. Would you like to waive the probationary period for ALL existing employees at initial enrollment? 10. Do you wish to offer coverage for domestic partners? 11. Under the Medicare Secondary Payer rules, which one applies for your group? Medicare is primary (less than 20 employees) Anthem Blue Cross and Blue Shield is primary (20 or more employees) Anthem Blue Cross and Blue Shield is primary coverage for groups with 20 or more total employees on each working day in each of 20 or more calendar weeks in the current calendar year or the preceding calendar year. 12. Is your company currently subject to COBRA (employed 20 or more total employees on at least 50% of the working days in the previous calendar year)? 13. How many months are employees eligible to continue group coverage while on an employer-approved temporary medical leave of absence (maximum six months)? None 1 month 2 months 3 months 4 months 5 months 6 months 14. How many months are employees eligible to continue group coverage while on an employer-approved temporary personal leave of absence (maximum three months)? None 1 month 2 months 3 months 15. We, the Employer, attest that the Employer Group named on this application is a Nevada Small Group consistent with the definition below. *NV law defines small employer as follows: The term small employer means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least one but not more than 50 employees on business days during the preceding calendar year and who employs at least one employee on the first day of the plan year. 5 of 8

6 Section E: General Agreement Please read this section carefully before signing the application. Electronic Access of Group Information by Agent/Producer/Broker/General Agent We, the employer, hereby authorize the agent/producer/broker/general agent whose name is attached to this application to use the EmployerAccess system of Anthem Blue Cross or Anthem Blue Cross Life and Health Insurance Company to access the group s information, such as but not limited to enrollees, plan selections, and bills/invoices. Such agent/producer/broker/general agent is also hereby authorized to use the EmployerAccess system of Anthem Blue Cross or Anthem Blue Cross Life and Health Insurance Company to make changes to the group s information on behalf of the group, such as but not limited to adding/deleting plans, adding/deleting employees, and or changing employee demographic information. These authorizations shall terminate if the group s designated agent/producer/broker/general agent changes. Check this box ONLY in the group elects to opt-out of authorizing the agent/producer/broker/general agent to access and change the group s information on behalf of the group. Terms and Conditions The undersigned employer and/or authorized representative hereby request(s) approval for insurance coverage by Anthem Blue Cross and Blue Shield/Anthem and/or HMO Nevada and/or Anthem Life. Our signature below will indicate that Anthem Blue Cross and Blue Shield/Anthem and/or HMO Nevada and/or Anthem Life are approving coverage. By signing this application, the undersigned employer agrees to be bound by the terms of the contract. The employer agrees that: 1. The requested coverage is not in effect until this application is approved by Anthem Blue Cross and Blue Shield/Anthem and/or HMO Nevada and/or Anthem Life; that approval of coverage shall be evidenced by issuing insurance contracts and/or policies to the employer; and an employee s coverage is not in effect unless and until the employee application is approved for coverage by Anthem Blue Cross and Blue Shield/Anthem and/or HMO Nevada and/or Anthem Life. The employer must meet the minimum enrollment, participation and eligibility requirements according to the applicable Anthem underwriting policies and Nevada state law. 2. The advance premium check does not create temporary or interim insurance coverage, and receipt and deposit of that payment does not guarantee issuance of insurance coverage; rather, issuance of insurance coverage is expressly conditioned on Anthem Blue Cross and Blue Shield/Anthem and/ or HMO Nevada and/or Anthem Life s determination that the employer satisfies Anthem Blue Cross and Blue Shield/Anthem and/or HMO Nevada and/ or Anthem Life s current underwriting practices and procedures. Unless these conditions are met, there shall be no liability on that part of Anthem Blue Cross and Blue Shield/Anthem and/or HMO Nevada and/or Anthem Life, except to refund the advance premium payment. The employer will be responsible for returning to individual employees any part of the payment contributed by those employees. 3. For Anthem Blue Cross and Blue Shield/Anthem and/or HMO Nevada and/or Anthem Life to accept this application, all the information requested on this application must be completed. If the application is not complete, Anthem Blue Cross and Blue Shield/Anthem and/or HMO Nevada and/or Anthem Life or their designated agent(s) are authorized to obtain the necessary information and to complete that information on this application. The employer understands that the coverage issued by Anthem Blue Cross and Blue Shield/Anthem and/or HMO Nevada and/or Anthem Life may be different from the coverage applied for herein. If Anthem Blue Cross and Blue Shield/Anthem and/or HMO Nevada and/or Anthem Life notifies the employer of such different coverage, and the employer pays the appropriate premium, the employer will be deemed to have accepted the coverage as issued. 4. By signing below, I, the employer, agree that Anthem can deliver plan materials and related items, including but not limited to benefit booklets, summaries, billing statements, notices of non-payment and cancellation and other notices, via or other electronic means. I agree that I will provide and update Anthem with a current address. I understand that at any time I can request a free copy of these materials by mail, by contacting Anthem at or via the EmployerAccess system. Sign Company officer signature Printed name Title Date (MM/DD/YYYY) here X Accepted by officer of Anthem Blue Cross and Blue Shield and/or Anthem Life Date (MM/DD/YYYY) 6 of 8

7 Section F: Agent Certification 1. I am not aware of any information not disclosed by the client in this application that may have bearing on this risk. 2. I have not completed any of the information contained in the application except with the permission of the applicant and as noted by my initials and date on the application. 3. I have not signed any of the applications for an employer representative or individual applicant. If after submission of this application, I request any additions or changes to any of the above information, I will do so only with the written consent of the applicant, and I authorize Anthem Blue Cross and Blue Shield/Anthem and/or HMO Nevada and/or Anthem Life to attribute such additions or changes to me. 4. I have advised the employer that a failure to provide complete and accurate information may result in a loss of coverage retroactive to the effective date of coverage or re-rating of the employer s premium retroactive to the coverage effective date and that coverage shall not be effective until Anthem Blue Cross and Blue Shield/Anthem and/or HMO Nevada and/or Anthem Life reviews and approves the application and the employer receives a written notice from Anthem Blue Cross and Blue Shield/Anthem and/or HMO Nevada and/or Anthem Life. 5. I am the appointed agent/broker and am receiving commissions for the submission of this client. No portion of my commission payments from Anthem Blue Cross and Blue Shield/Anthem and/or HMO Nevada and/or Anthem Life shall be paid to an agent/broker/producer not appointed/approved by Anthem Blue Cross and Blue Shield/Anthem and/or HMO Nevada and/or Anthem Life. 6. I have advised the client not to terminate any existing coverage until receiving written notification from Anthem Blue Cross and Blue Shield/Anthem and/or HMO Nevada and/or Anthem Life that the coverage being applied for by this application is accepted. Writing Agent % Second Writing Agent % Agency name Agency ID no. Agency name Agency ID no. Agent name Federal tax ID no. or Social Security no. Street address Agent name Federal tax ID no. or Social Security no. Street address City State ZIP code City State ZIP code Phone no. Fax no. Phone no. Fax no. address address Signature Date (MM/DD/YYYY) Signature Date (MM/DD/YYYY) General agent name For General Agent use only Federal tax ID no. or Social Security no. Street address City State ZIP code Sales representative name Account manager name Sales Representative and Account Manager Sales representative ID no. Account manager ID no. ANTHEM USE ONLY Group no. Tracking no. Effective date (MM/DD/YYYY) 7 of 8

8 Checklist for Anthem/HMO Nevada New Group 1. Employer Enrollment Application Please ensure all fields within the application are completed, signed and dated. Incomplete applications may be returned, which could delay the processing of your application. 2. Original quote/proposal for all lines of coverage for which you are applying for the correct effective date. 3. Include a check for the first month s premium payable to Anthem Blue Cross and Blue Shield or HMO Nevada. The check must be imprinted with the company name and address. Personal non-company checks cannot be accepted. 4. Include a copy of your most recent Nevada Quarterly Wage Report needs to be justified. Indicate employee status next to each employee s name, i.e., enrolling, waiving, terminated and date, part-time, seasonal, etc. Please note that if the group has a new hire who is not reflected on the Quarterly Wage Report, then we require the most recent payroll. If owner(s) do not take a salary they are required to submit business documentation to verify eligibility. Please review our underwriting guidelines for required documents Contractors: please review our underwriting guidelines for required documents. 5. Employee Enrollment Form(s) for each eligible employee enrolling and/or Employee Waiver(s) for employees declining coverage. Please submit your New Group to: Anthem Blue Cross and Blue Shield Attn: Small Group Sales 9133 W. Russell Road Las Vegas, NV Fax: sgnewbusiness@anthem.com Got questions? Contact your local Sales Representative For more information online, please visit anthem.com Cut-off-dates 1st of the month effective date: application due by the last business day of the month 15th of the month effective date: application due by the 12th of the month Incomplete applications will be sent back to you for completion. This may delay the effective date of your coverage. 8 of 8