Is the business a candidate for small employer group coverage? (2 50 total eligible employees on payroll)

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1 SMALL GROUP Submission Checklist Use the following checklist along with the TIPS for Submitting New Regulated Small Groups brochure to help you prepare and submit enrollment information for new small groups. Is the business a candidate for small employer group coverage? (2 50 total eligible employees on payroll) Proof of Business Required only if current Texas Wage and Tax Report is not available; see TIPS brochure for examples Small Group Employer Application (SGEA) Must be completed, signed and dated by the employer (get the most current version of the form at Employee Enrollment Applications Application or declination for each eligible employee is required; employees must complete, sign and date Signed Small Group Proposal Submit the signature page from the proposal with the Group Administrator s signature, the date and the plan(s) selected Proof of Wages Most recent quarterly Texas Wage and Tax Report (TWC) or other examples as listed in the TIPS brochure Texas Supplemental Employee Verification Form Needed for anyone (including new hires) not listed on the proof of wages documentation (i.e., payroll reports, TWC reports, etc.) Medicare Secondary Payer Form Must be completed, signed and dated by the employer Ensure Group Meets 75 Percent Participation Requirement Indicate employees who are part-time, seasonal and/or terminated Proxy Form Premium Payment Check Send paperwork to: Blue Cross and Blue Shield of Texas Small Business Service Center 1201 E. Campbell Road Richardson, TX Questions? Contact us at (800) Online Resource:

2 SMALL GROUP Important Timelines Step Who Does It Action Timing* 1. Broker/Producer Review all paperwork to check accuracy and completeness. When complete, submit new sold group paperwork to Blue Cross and Blue Shield (BCBSTX) Small Business Service Center at 1201 E. Campbell Rd., Richardson, TX Blue Cross and Blue Shield of Texas (BCBSTX) Verify accuracy and completeness of all paperwork. If additional or missing information is required, send to broker. When all requirements are received, forward the group to Underwriting. 3. BCBSTX During enrollment, all groups require review by Underwriting. Two different types of review could be warranted depending on medical conditions. At least 14 calendar days prior to the group s effective date Within two business days of receiving completed required documents Up to four business days after Step 2 NOTE: Medical review occurring during the preliminary quoting process does not negate the need for medical review during enrollment. 4. BCBSTX Develop final rates based on actual enrollment documentation submitted. BCBSTX generates either: A Rate Offer Letter, when actual enrollment differs from the proposal, or A Welcome Letter, when actual enrollment matches the proposal 5. Broker/Producer When applicable, have employer review and sign the Rate Offer Letter. or fax the signed Rate Offer Letter to the Small Business Service Center representative who sent it out. NOTE: Welcome Letters do not require signatures. 6. BCBSTX Final membership processing occurs after BCBSTX either: A) sends out a Welcome Letter, or B) receives the signed Rate Offer Letter IMPORTANT: Members are not eligible for benefits until this step is completed. 7. BCBSTX Generate identification cards for members. Within one business day after underwriting is complete Within three business days of receiving the Rate Offer Letter Within two to four business days of mailing the Welcome Letter or receiving the signed Rate Offer Letter Upon completion of Step 6 NOTE: BCBSTX mails the identification cards via the U.S. Postal Service; delivery times may vary. 8. BCBSTX Mail Administrative Guide to the employer. Within 30 days of the group s effective date *The Timing column represents BCBSTX processing target goals and is not a guarantee. A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

3 TEXAS SUPPLEMENTAL EMPLOYMENT VERIFICATION To be used with the TWC Report Employer s Name SIC Code Group Policy Number Address City State Zip EMPLOYEE CENSUS INFORMATION Under our Small Group Employer products, BCBSTX verifies employment information. We require the submission of a current TWC Report. The TWC Report is used to verify the SIC Code applicable to your company and to assist us in verifying employment. Please utilize the status codes listed below to denote the employment status of all employees listed on your TWC Report. Employees who are not indicated on the TWC Report should be reported using this Supplemental Employment Verification Form. All full-time employees must complete a BestChoice Application indicating (1) they are requesting coverage or (2) they are declining coverage. Applications for individuals requesting coverage cannot be processed without verification of employment. If this information is missing, the effective date of coverage may be delayed. STATUS CODES Please use the appropriate code indicating applicable status of the person listed on the TWC Report or this form: F P I O D C T W Full-time employee who works 30 or more hours per week Part-time employee who works less than 30 hours per week Independent contractor working 30 or more hours per week Owners, Partners and Officers who work 30 or more hours per week Totally disabled employee Continued employee under State or Federal law Terminated employee no longer employed by the company Full-time employees in Waiting Period EMPLOYEES NOT LISTED ON THE TWC REPORT Please list the following persons employed by you: New employees who do not appear on your TWC Report and work a minimum of 30 hours per week Owners, Partners and Officers who work a minimum of 30 hours per week Independent contractors who work a minimum of 30 hours per week (List only if offering coverage. It is not necessary for you to offer coverage to Independent Contractors; however, you must offer coverage to all Independent Contractors who work for you if you wish to cover any Independent Contractors.) Other (Please define employees who fall into this category so BCBSTX may determine if they are eligible for coverage.) These Persons Must Be Listed Even If They Decline Coverage Blue Cross and Blue Shield of Texas, A Division of Health Care Service Corporation, A Mutual Legal Reserve Company, An Independent Licensee of the Blue Cross and Blue Shield Association Revised bestdocs\eligform.doc

4 NAME DATE OF FULL-TIME EMPLOYMENT HOURS WORKED PER WEEK STATUS CODE APPLYING FOR COVERAGE (YES) DECLINING COVERAGE (NO) ATTACH APPLICATION 1 Yes No 2 Yes No 3 Yes No 4 Yes No 5 Yes No 6 Yes No 7 Yes No 8 Yes No 9 Yes No 10 Yes No 11 Yes No 12 Yes No 13 Yes No 14 Yes No 15 Yes No 16 Yes No 17 Yes No 18 Yes No 19 Yes No 20 Yes No 21 Yes No 22 Yes No 23 Yes No 24 Yes No 25 Yes No I HEREBY CERTIFY I HAVE READ THIS DOCUMENT AND THE INFORMATION PROVIDED IS ACCURATE AND COMPLETE. I ALSO CERTIFY THE INFORMATION PROVIDED HERE CAN BE SUBSTANTIATED BY BUSINESS RECORDS MAINTAINED BY ME. UPON REQUEST, I AGREE TO PROVIDE THE DOCUMENTATION REQUESTED BY BCBSTX VERIFYING PARTICIPATION AND ELIGIBILITY REQUIREMENTS. I UNDERSTAND PROVIDING INCOMPLETE, INACCURATE, OR UNTIMELY INFORMATION MAY VOID, REDUCE OR TERMINATE THE GROUPS COVERAGE. Signature of Authorized Company Official Title Date Print Name of Authorized Company Official Signature of Agent BCBSTX does reserve the right to randomly request documents verifying the above information. In addition, we reserve the right to reverify employment information at any time during the course of your contract with us. Blue Cross and Blue Shield of Texas, A Division of Health Care Service Corporation, A Mutual Legal Reserve Company, An Independent Licensee of the Blue Cross and Blue Shield Association Revised bestdocs\eligform.doc

5 Health No. Life No. SMALL GROUP EMPLOYER APPLICATION You have the option to choose a Consumer Choice of Benefits Health Insurance Plan or Consumer Choice of Benefits Health Maintenance Organization health care plan that, either in whole or in part, does not provide state-mandated health benefits normally required in accident and sickness insurance policies or evidences of coverage in Texas. This standard health benefit plan may provide a more affordable health insurance policy or health plan for you, although, at the same time, it may provide you with fewer health benefits than those normally included as state-mandated health benefits in policies or evidences of coverage in Texas. If you choose this standard health benefit plan, please consult with your insurance agent to discover which state-mandated health benefits are excluded in this policy or evidence of coverage (Certificate of Coverage). (See page 3, Consumer Choice Plans, for available plan options and page 9 for the Disclosure Statement that applies to these plans.) Legal Name of Company: Nature of Business: SIC Code Physical Address (number & street), City, State, ZIP: Address of Authorized Company Official: Telephone Number: FAX Number: Secondary Address, if different from Authorized Company Official: Complete Mailing Address, if different from physical address: Billing and Correspondence to the attention of: The Blue Access for Employers (BAE) contact person is the individual authorized by the Employer to access and maintain its account/employee information. Name and title of the BAE contact person: Address of BAE contact person: Requested Contract(s)/Policy(ies) Effective Date (1 st or 15 th ): / / Month Day Year Will you have been uninsured for at least 2 months prior to the requested Effective Date of this coverage? Yes No Note: Products with a Health Maintenance Organization (HMO) component must be effective on the first day of the month. Contract/Policy Anniversary Dates will be 12 months from the Effective Date. A copy of your most recent Texas Workforce Commission (TWC) Report(s) or other supporting documentation must be submitted with this application (please identify part-time employees and terminations). W4s, 1099s, or a Texas Supplemental Employment Verification form must be submitted for any applicants not included on the TWC Report. 1. Waiting Period: Newly eligible individuals will become effective on the first day of the contract/participation month following satisfaction of the Waiting Period selected: 0 days 30 days 60 days 90 days Waive the Waiting Period on initial group enrollment? Yes No Number of employees serving Waiting Period: Employee and dependent Health and/or Dental Benefit Plans will become effective on the first day of the contract/participation month following satisfaction of the Waiting Period, if any. 2. Total number of applications submitted: Total number of declinations submitted: 3. Do all employees reside in Texas? Yes No If no, is Texas the state with the greatest number of employees eligible to enroll in this group plan? Yes No Fort Dearborn Life is a separate company that does not provide Blue Cross and Blue Shield of Texas products or services. Fort Dearborn Life is solely responsible for the life and disability coverage provided. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Fort Dearborn Life Insurance Company, a Member of the Preferred Financial Group Form No. SERA27 Page 1

6 4. Is the company headquarters in Texas? Yes No Health No. Life No. 5. Are you a public entity group? Yes No A public entity is a State, any of its counties, departments, agencies, independent school districts, or other political subdivisions. 6. Are you an independent school district that is a large employer electing to participate as a small employer? Yes No 7. Are any employees currently receiving Workers Compensation benefits? Yes No If yes, list names and conditions*: TEFRA AND COBRA ARE FEDERALLY MANDATED AND APPLY TO EMPLOYERS WITH 20 OR MORE FULL-TIME OR PART-TIME EMPLOYEES. EMPLOYER PENALTIES FOR NONCOMPLIANCE MAY APPLY. 8. TEFRA. The Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) is a Medicare secondary payer requirement that mandates employers that employ 20 or more (full-time, part-time, seasonal, or partners) total employees for each working day in each of 20 or more calendar weeks in the current or preceding calendar year to offer the same (primary) coverage to their age 65 or over employees and the age 65 or over spouses of employees of any age that they offer to younger employees and spouses. (See page 10 for more Medicare Secondary Payer Rules information) Are you subject to the Tax Equity and Fiscal Responsibility Act (TEFRA)? Yes No 9. COBRA. a. Did your company employ 20 or more full-time and/or part-time employees for at least 50% of the workdays of the preceding calendar year? Yes No b. Are you subject to the Consolidated Omnibus Budget Reconciliation Act (COBRA)? Yes No If yes, list names and number of individuals (qualified beneficiaries) currently on COBRA continuation*: (See page 10 for more COBRA information) 10. State Continuation Privilege on Termination of Coverage. All employees, members, or dependents are entitled to state continuation of group coverage under certain conditions. List names and number of continued persons currently on state continuation coverage*: State Continuation of Group Coverage for Certain Dependents. A dependent of an insured is entitled to state dependent continuation under certain conditions. List names and number of continued dependents on state (3 years) dependent continuation coverage*: 11. If you currently have group health care coverage with another carrier, complete the following: a. Present health carrier s name: b. Paid-to-date with current carrier: / / Month Day Year c. Calendar year medical deductible amount with current carrier: Individual: Family: BCBSTX GROUP PLANS COMPLY WITH THE FEDERAL REQUIREMENTS FOR COVERAGE OF MATERNITY CARE. EMPLOYER PENALTIES FOR NONCOMPLIANCE MAY APPLY. Please check the one option below that applies to your company in regards to maternity care. 12. a. We are selecting a MOP, HMO (only), Triple Option Plan, or Consumer Choice HMO (only) plan. We understand maternity care is automatically included in the coverage for these small group employer plans. b. We are selecting a PPO or Consumer Choice PPO plan and have 15 or more full or part-time employees. We understand maternity care is automatically included in the coverage as required by federal law. c. We are selecting a PPO or Consumer Choice PPO plan and have less than 15 full or part-time employees. We have indicated below whether we would like to accept or decline maternity coverage. (Do not complete the checkboxes below if you selected option (a) or (b) above.) Accept Maternity Coverage Decline Maternity Coverage * If needed, additional space for required information is available on page 8 of this form. Form No. SERA27 Page 2

7 Health No. Life No. Application is hereby made to Blue Cross and Blue Shield of Texas (herein called BCBSTX): BESTCHOICE PREFERRED PROVIDER (PPO): PPO plan selected: Dual PPO plans selected: Plan #1 Plan #2 BlueEdge HSA/HDHP* selected: If BlueEdge HSA/HDHP is selected, provide name of HSA administrator/trustee: BlueEdge Wellness Rewards HCA plan selected: HMO: (100% of eligible employees must reside or work in the service area. The HMO Blue Texas service area does not include all counties in Texas.) HMO Blue plan selected: (HMO plans 9 and are available) MULTIPLE OPTION PLAN (MOP) BestChoice PPO plan selected: HMO Blue plan selected: (HMO plans 9 and are available) BlueEdge HSA/HDHP plan selected: If BlueEdge HSA/HDHP is selected, provide name of HSA administrator/trustee: BlueEdge HCA plan selected: Serious Mental Illness, Speech and Hearing Services, and In Vitro elections must be the same for PPO or BlueEdge Plans and HMO Plans. TRIPLE OPTION PLAN Plan #1 Plan #2 Plan #3 Three HSA plans and/or HCA plans are allowed. One of the following is required: an HSA plan, an HCA plan, S32, S33, or S34. Only one HMO plan is allowed. Serious Mental Illness, Speech and Hearing Services, and In Vitro elections must be the same for PPO or BlueEdge Plans and HMO Plans. Was a 100% contribution plan selected? Yes If yes, Employer confirms that 100% contribution is being paid toward the Employee Only premium No If no, Employer confirms that a minimum of 50% contribution is being paid toward the Employee only premium PPO or BlueEdge Plans The following mandated benefit offers are made by BCBSTX in compliance with Texas regulations. Please mark your acceptance or declination. Acceptance may result in a rate adjustment. Serious Mental Illness (SMI) (must choose one) Accept Inpatient days limited to 45 Decline If declined, benefits for SMI are included in the benefits for Mental Health Care Public entities must cover SMI same as any other illness In Vitro Fertilization Services (must choose one) Accept Benefits are paid same as any other medicalsurgical expense Decline If declined, no benefits are available Speech and Hearing Services (must choose one) Accept Benefits are paid same as any other illness Decline If declined, therapy is covered same as any other illness; hearing aid benefit is limited to $1,000 max every 36 months Home Health Care (must choose one) Accept Maximum of 60 visits each Calendar Year Decline If declined, the standard benefit of $10,000 each Calendar Year will apply Form No. SERA27 Page 3 HMO Serious Mental Illness (SMI) (must choose one) Accept Inpatient days limited to 45 Decline If declined, benefits for SMI are included in the benefits for Mental Health Care Public entities must cover SMI same as any other illness (SM2) In Vitro Fertilization Services (must choose one) Accept Limited Benefits Decline If declined, no benefits are available Speech and Hearing Services (must choose one) Accept Benefits are paid same as any other illness Decline If declined, medically necessary speech therapy is covered on an outpatient basis only; limited hearing. Hearing aids are covered under a DME additional benefit option only Additional Benefit Options Inpatient Mental Health (IPMH): IM1 IM2 Vision: IC O2 Durable Medical Equipment (DME): DM1 DM2 CONSUMER CHOICE PLANS (These options are offered in place of PPO-only, HMO-only, MOP, or Triple Option Plan) Consumer Choice PPO coverage Consumer Choice HMO coverage Pharmacy Benefits Option 99 (20/35/50) If a Consumer Choice Plan is accepted, please sign Disclosure Statement on page 9. DENTAL BENEFIT PLANS Dental Benefit Plan selected: Dual Option Dental Benefit Plans selected: Plan #1 Plan #2 * Health Savings Account (HSA) - High Deductible Health Plan (HDHP) Health Care Account (HCA)

8 Health No. Life No. SMALL GROUP EMPLOYER MEDICAL QUESTIONNAIRE Complete the following questions to the best of your knowledge for eligible employees, their dependents, and any COBRA participants, state continuation participants, or state dependent continuation participants. If your current carrier is BCBSTX, your response to the medical questions should be based on eligible employees and/or dependents not currently on your employee group health plan. If BCBSTX is your current carrier, provide your Group/Account Health Number: 1. How many employees or dependents have had a claim of $5000 or more in the past 12 months? 2. How many employees or dependents have been advised to have surgery or medical treatment in the past 6 months that has not yet been performed, or been hospitalized or had surgery in the past 3 years? 3. How many employees or dependents have been advised, diagnosed, or treated by a physician in the past 5 years for: (Enter the number of employees or dependents with the condition and provide details on the next page.) A. Stroke Heart Disease or Disorder Circulatory Disease or Disorder Vascular Disease or Disorder High Blood Pressure B. Cancer Tumors Leukemia Chronic Skin Condition Lupus Any other Systemic Disease C. Multiple Sclerosis Paralysis Osteoarthritis Joint Disorders Muscle Disorders Other Severe Arthritis Back Disorders Bone Disorders D. Asthma Emphysema Respiratory and Lung Disorders E. Diabetes Pancreas Growth Disorder Endocrine Disorder F. AIDS Tested Positive for HIV Immune System Disorders Blood Disorders G. Hepatitis Liver Disorder Digestive System Disease or Disorder Kidney Disorder Reproductive Organs Disorder Colon Disorder Prostate Disorder Infertility Urinary Tract Disorder H. Nervous System/Brain/Seizure Disorders Mental/Emotional Disorders Alcohol/Drug/Substance Abuse or Dependency I. Organ Transplant Bone Marrow Transplant J. Other 4. How many employees or dependents are currently pregnant? Form No. SERA27 Page 4

9 Health No. Life No. If you have indicated medical conditions on the previous page, please provide details for each person with the condition. If more than one person has the condition, add a separate entry for each person. See the example in the first line. Name of Person with Condition (Optional) Age Gender Relation to Insured* Condition/ Diagnosis Details Treatment/ Medication Details Date(s) Treated Current Status John Doe Example 12 M Child Appendicitis Surgery to remove appendix 01/01/99 to 01/05/99 Full recovery * Employee, Spouse, Child I understand the information on this form and any other medical information provided to BCBSTX in prior preliminary medical requests or otherwise provided to BCBSTX, is the basis for premium determination by BCBSTX for the health plan. I acknowledge that false statements or material misrepresentations may result in legal consequences. I certify the information is complete and true to the best of my knowledge. For Employer: For Agent: Name of Authorized Company Official (print name) Name of Agent, if applicable (print name) Signature of Authorized Company Official Signature of Agent Form No. SERA27 Page 5

10 Health No. Life No. The Employer understands and agrees to comply with the following requirements regarding the Health Benefit Plan (Plan), inclusive of the Dental Benefit Plan, when Dental coverage is elected: Applications/Declinations are attached for all full-time employees as well as any COBRA or state participant continuations. Minimum Participation Requirement: A small employer must maintain enrollment of at least 75% participation of eligible employees under this Health Benefit Plan and 75% participation under the Dental Benefit Plan, when Dental coverage is elected. Employer Contribution: A small employer must contribute a minimum of 50% of the employee only premium for the Health Benefit Plan selected for all enrolled employees. Certain small employer Health Benefit Plans available require the employer to contribute 100% of the premium for each eligible participating employee. A small employer must contribute 50% of the employee only premium for the Dental Benefit Plan for all enrolled employees, when Dental coverage is elected. The Employer must provide eligibility and enrollment information, effective dates of employment, and all other data necessary for the efficient administration of the Health Benefit Plan and Dental Benefit Plan, when Dental coverage is elected, according to the terms and requests of BCBSTX. After approval by BCBSTX for the Health and/or Dental Benefit Plan applied for, individuals will become effective on the first day of the contract/participation month following satisfaction of the Waiting Period (if any, but not to exceed 90 days). Employees whose applications are received more than 31 days after date-of-hire or received after expiration of the Waiting Period will be considered late enrollees and will be eligible to enroll during the next open enrollment period. Appropriate credit for time served under a previous Health Benefit Plan will be applied toward the pre-existing condition waiting period for BestChoice preferred provider Health Benefit Plan(s). The Employer, while not an agent of BCBSTX, will be responsible for collection of premiums from employees, will notify employees of the termination of their coverages and will forward to employees notices and/or amendments sent by BCBSTX to the Employer. The Employer will be bound by the terms of the Contract(s)/Policy(ies) issued pursuant to the Application and such shall serve as the basis to resolve any conflict. When issued, the Contract(s)/Policy(ies) will include this Application and any Addenda issued pursuant to this Application. Premium rates for the coverages applied for are determined by BCBSTX and will become a part of the Contract(s)/Policy(ies) issued by BCBSTX and any amendments thereto. This Application and all enrollment materials must pre-date the requested effective date and be received by BCBSTX at its Home Office no later than the Contract/Policy effective date. (Applications may not pre-date the requested effective date by more than 45 days.) Retirees are not eligible for coverage under this Health Benefit Plan or under the Dental Benefit Plan, when Dental coverage is elected. Under state law, eligible employee means an employee who works on a full-time basis and who usually works at least 30 hours a week. The term includes a sole proprietor, a partner, and an independent contractor, if the individual is included as an employee under a health benefit plan of a small employer regardless of the number of hours the sole proprietor, partner, or independent contractor works weekly, but only if the plan includes at least two other eligible employees who work on a full-time basis and who usually work at least 30 hours a week. The term does not include an Employee who: (1) works on a part-time, temporary, seasonal, or substitute basis, or (2) is covered under (a) another Health Benefit Plan, or (b) a selffunded or self-insured employee welfare benefit plan that provides health benefits and that is established in accordance with the Employee Retirement Income Security Act of 1974, or (3) elects not to be covered under the small employer s health benefit plan and is covered under (a) the Medicaid program; (b) another federal program, including the TRICARE program or Medicare program; or (c) a benefit plan established in another country. ERISA Plan Year / (See page 10 for more ERISA information or contact your Legal Advisor) Month Year If you contend ERISA is inapplicable to your health plan, please state the basis: Form No. SERA27 Page 6

11 Health No. Life No. Application is hereby made to Fort Dearborn Life Insurance Company (herein called FDL) for a Life Insurance Plan (including Term Life Insurance, Accidental Death and Dismemberment (AD&D), Dependents Life, and/or Short Term Disability (STD). I. Group Life Administration Information Eligibility: All active employees All active employees enrolled for health insurance who work a minimum of 30 hours per week excluding seasonal, temporary, or retired employees Benefit: Class All employees according to the following schedule: Job Title, as shown on the enrollment form Life & AD&D Benefit Amount STD Amount (if elected) Total eligible employees: Total enrolling: Term Life/AD&D Dependents Life STD First Contract Anniversary Date: 12 months from Contract Effective Date Other II. Term Life Insurance and AD&D: Applied For Not Applied For Complete Life and AD&D Benefit Amount in Section I Guarantee Issue Maximum: $ Rates: Step-Rated Composite Rated (Include a copy of the rating exhibit if rated in the field) Employer Contribution: 100% Other % (Minimum 25% Employer contribution required) Life/AD&D Reductions due to Attained Age (All benefits terminate at retirement): Reduces by 35% at age 65, to 50% of the original benefit at age 70, to 25% of the original benefit at age 75, and to 15% of the original benefit at age 80. (Standard under 10 eligible lives) Reduces by 35% at age 65 and to 50% of the original benefit at age 70. (Unavailable under 10 eligible lives) Reduces to 50% at age 70. (Unavailable under 10 eligible lives) Term Life is in addition to, or replacement of current term life coverage If replacement, give current carrier: no current carrier Termination date of prior plan: III. Dependents Term Life Insurance: Applied For (offered only with Term Life/AD&D) Not Applied For Benefits: Spouse: $ Rate: $ Child(ren) age 15 days up to 6 mos: $ Employer Contribution: % Child(ren) age 6 mos. up to age 25 & Students: $ IV. Short Term Disability (STD) Insurance: Applied For (offered only with Term Life/AD&D) Not Applied For Wage-Based Benefit: 50% 60% 66 2/3% of Basic Weekly Wages to a Benefit Maximum of $ Flat Benefit: $50 $100 $150 $200 $250 not to exceed 66 2/3% of Basic Weekly Wages Class Defined Plan: Complete STD amount in Section I Benefits Begin: Due to an Accident: (select one) Due to Sickness: (select one) 1 st day 8 th day 15 th day 31 st day 8 th day 15 th day 31 st day Maximum Weekly Benefit Duration: 13 weeks 26 weeks Rates: Step-Rated Composite Rated (Include a copy of the rating exhibit if rated in the field) Employer Contribution: 100% Other % (Minimum 25% Employer contribution required) STD is in addition to, or replacement of current STD coverage no current STD carrier If replacement, give current carrier: Termination date of prior plan: STD benefits are payable for non-occupational disabilities only. STD benefits terminate at retirement. Form No. SERA27 Page 7

12 Health No. Life No. The undersigned represents he/she is an Employer engaged in (groups with 2 to 9 employees must check one): Wholesale, Retail, or Distribution Business; or Service Business; or Manufacturing Business The Employer agrees to comply with all terms and provisions of the Group Life and/or Disability Contracts(s) issued, and trust agreements, if applicable, and also accepts enrollment under the FDL trust policy(ies), if applicable. The Employer further agrees to comply with the following requirements: 1. For Life and STD, if coverage is contributory, a minimum of 75% of the eligible employees must enroll. If coverage is non-contributory, 100% of the eligible employees must enroll. 2. Group term life, for groups with less than ten (10) eligible employees, may be sold on a contributory basis, however, in no event may the contribution by the insured employee exceed forty cents ($0.40) per thousand dollars of coverage per month. 3. STD may be sold on a contributory basis, however, the Employer must contribute a minimum of 25%. STD is available only if group term life and AD&D is selected. 4. Coverage for employees who are not actively at work, as defined in the policy, on the date their coverage would otherwise become effective will be deferred until the date they return to active work. 5. If life and AD&D benefits are selected by occupational class, there must be at least one eligible employee in each class, and no class may have a benefit greater than 2½ times the amount for the next lower class. 6. The Employer shall remit all required premium payments to FDL no later than the first day of each billing period. If the premium payments are not received by FDL, insurance for the Employer and all covered employees shall cease in accordance with the terms of the Policy. 7. The Employer shall provide eligibility and enrollment information, dates of employment, and all other data necessary for the efficient administration of the FDL Life and/or Disability Insurance Plan. 8. Coverage for the Employer may be amended from time to time, and the Employer s participation may be terminated with 31 days written notice by FDL in accordance with the terms of the Policy. FDL reserves the right to change premium rates for reasons including, but not limited to, change in benefit design or Policy terms, change of industry, utilization within the industry, or other factors bearing on the assumed risk. 9. FDL reserves the right to terminate the Employer s participation in the Life Insurance Plan if the Employer fails to maintain compliance with the requirements set forth herein. 10. Benefit amounts in excess of the guarantee issue and all late applications for contributory coverage are subject to satisfactory evidence of insurability. The Employer agrees not to collect any premium from employees on amounts for which satisfactory evidence of insurability is required until notified by FDL of the approval of the employee s application for coverage. EMPLOYER: DO NOT CANCEL CURRENT COVERAGE UNTIL NOTIFIED BY BCBSTX AND/OR FDL THAT THIS APPLICATION HAS BEEN APPROVED. *Additional Information: Include list of COBRA and/or state continuation participants or state dependent continuation participants, anyone currently receiving Workers Compensation benefits, and the names of any full-time employees NOT submitting an application/declination (give reason). Form No. SERA27 Page 8

13 Health No. Life No. ELECTRONIC RECEIPT OF CERTIFICATE-BOOKLETS AND CONTRACTS The Employer consents to receive an electronic file (E-file) version of the certificate-booklets provided by BCBSTX for covered employees. The Employer also agrees to receive E-files of all documents that together constitute the contract between the Employer and BCBSTX (the Contract ). In providing this consent, the Employer agrees to and/or understands that: (1) the E-file certificate-booklet provided by BCBSTX is a certificate-booklet and is not intended to satisfy all ERISA compliance regulations as a summary plan description (SPD); (2) the Employer is aware of the basic requirements established by Department of Labor regulations governing electronic distribution of coverage documents to employees; (3) the Employer is solely responsible for providing each insured employee access to the most current version of any E-file certificate-booklet, amendment, or other revised employee form provided by BCBSTX, or to provide a paper copy of the same to an employee upon request or to an HMO subscriber who has not agreed to accept the certificate of coverage electronically; (4) upon receipt, the Employer may receive paper copies of the Contract provided as an E-file; (5) as modifications are made to existing forms or when new, revised forms are necessary, they will be received via an E-file and all provisions above will apply. The Employer will rely on BCBSTX instructions to determine if the file is a replacement or addition to existing documents and will provide the information to employees accordingly; and (6) the Employer is solely responsible and holds BCBSTX harmless from any misuse of the E-file provided by BCBSTX; and (7) the electronic transmission shall be in the format specified by BCBSTX, and if transmission errors occur, the Employer will contact BCBSTX immediately to request redirection of the information. Decline Employer does not consent to receive electronic versions of certificate-booklets for covered Employees or the Contract and desires BCBSTX to print and distribute hard copy versions. DISCLOSURE STATEMENT (Only sign and complete this section if a Consumer Choice Plan was selected) I acknowledge this Consumer Choice of Benefit Health Insurance Plan or Consumer Choice of Benefits Health Maintenance Organization Health Care Plan (Plan), either in whole or in part, does not provide state-mandated health benefits normally required in accident and sickness insurance policies or evidences of coverage (Certificate of Coverage) in Texas. I am aware this Plan may provide more affordable health benefits, although, it may provide fewer health benefits than those normally included in policies or evidences of coverage (Certificate of Coverage) with state mandated health benefits in Texas. Excluded PPO State Mandates Excluded HMO State Mandates 1. Chemical Dependency 1. Chemical Dependency 2. Prescription Contraceptive Drugs 2. Prescription Contraceptive Drugs and Devices and Related Drugs and Devices and Related Drugs (Oral Contraceptives not excluded) (Oral Contraceptives not excluded) 3. In-Vitro Fertilization 3. In-Vitro Fertilization 4. Serious Mental Illness 4. Serious Mental Illness (non-public entities only) (non-public entities only) 5. Speech and Hearing (limited benefit) 5. Speech and Hearing 6. Home Health (limited benefit) For Employer: Name of Authorized Company Official (print name) Date Signature of Authorized Company Official Form No. SERA27 Page 9

14 Health No. Life No. Under the Medicare Secondary Payer Rules, it is your responsibility to annually inform BCBSTX of proper employee counts for the purpose of determining payment priority between Medicare and BCBSTX. To satisfy this responsibility at this time, please complete, sign, date, and return the Annual Medicare Secondary Payer Employer Acknowledgement Form along with this application. It is your responsibility to annually inform BCBSTX of whether COBRA is applicable to you based upon your full and part-time employee count in the prior calendar year. Failure to advise BCBSTX of a change of status could subject you to governmental sanctions. The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that sets minimum standards for employee benefit plans in the private industry. In general, all employer groups, insured or ASO, are subject to ERISA provisions except for: Governmental entities, such as municipalities; Public school districts, and church plans as defined by the Internal Revenue Code. I have read and understand this Employer s Application, and the agent, if any, named below is authorized to represent the Employer in the purchase of the Health Benefit Plan and/or the Dental Benefit Plan and/or Group Life Insurance Plan. I acknowledge that the agent(s) or agency(ies) named on the Agent s Statement page (page 11) is/are is acting on behalf of the Employer for purposes of purchasing Employer insurance, and that if BCBSTX/FDL accept this Small Group Employer Application and issues a Group Contract/Policy to the Employer, BCBSTX/FDL may pay the agent(s)/agency(ies) a commission and/or other compensation in connection with the issuance of such Group Contract/Policy. The undersigned further acknowledges that if the Employer desires additional information regarding any commissions or other compensation paid the agent(s)/agency(ies) by BCBSTX/FDL in connection with the issuance of a Group Contract/Policy, they should contact the agent(s)/agency(ies). I certify that all statements contained in this Small Group Employer Application and all information required to be furnished to BCBSTX/FDL are complete and true to the best of my knowledge and belief. I understand that BCBSTX/FDL will rely on the statements made and information furnished, as well as other medical information provided to BCBSTX/FDL from prior Preliminary Medical requests or otherwise provided to BCBSTX/FDL, as the basis in determining the appropriate rate level and/or approval of the Employer s Application. I understand that no insurance or changes will become effective without approval of BCBSTX/FDL. The requested Contract(s)/Policy(ies) effective date (as listed on page 1) is subject to change by BCBSTX/FDL if all required documents are not completed and received by the date requested. If documents are not received by the date requested, the Employer will be required to complete a new Small Group Employer s Application. For Employer: Name of Authorized Company Official (please print) Signature of Authorized Company Official Title City and State of signing official Date Form No. SERA27 Page 10

15 AGENT S STATEMENT TO BE COMPLETED BY AGENT(S) - PLEASE PRINT Health No. Life No. Agent s Statement I certify that I have reviewed all enrollment materials and I have advised the Employer not to terminate any existing coverage(s) until receiving notice that BCBSTX/FDL have accepted and approved this Employer Application. I have advised the Employer of its rights as a small group employer to purchase one of the Consumer Choice of Benefits Plans. I have also advised the Employer that I have no authority to bind these coverages, to alter the terms of the Contract(s)/Policy(ies), this Employer Application, or enrollment material in any manner or to adjust any claims for benefits under the Contract(s)/Policy(ies). Writing Agent s name (please print) Address Writing Agent s signature Agent # Date Telephone # 1. Primary Agent or Agency Name* (to whom commissions are to be paid): (Please also use 2. below, for split commissions) Percentage of Split**: Street, City, ZIP: Tax ID/SSN: Agent #: FAX number: Name and phone # of agent to contact for this case: Contact s address (please print clearly): 2. Agent or Agency Name* (to whom commissions are to be split): Percentage of Split**: Street, City, ZIP: Tax ID/SSN: Agent #: FAX number: Contact s address (please print clearly): 3. General Agent Name (if applicable): Street, City, ZIP: Tax ID/SSN: Agent #: FAX number: Contact name and telephone number for this case: Contact s address (please print clearly): General Agent s Signature: * The agent or agency name(s) above to whom commissions are to be paid must exactly match the name(s) on the appointment application(s). ** If commissions are to be split, please provide the information requested above on both agents or agencies. BOTH must be appointed to do business with BCBSTX and/or FDL. Form No. SERA27 Page 11

16 EMPL BLUE CROSS AND BLUE SHIELD OF TEXAS (BCBSTX) MEDICARE SECONDARY PAYER (MSP) EMPLOYER ACKNOWLEDGEMENT FORM (EAF) Under federal law, it is the Employer s responsibility to inform its insurer or third-party administrator of proper employee counts for the purpose of determining payment priority between Medicare and another insurer. Employer size, not group health plan size, is used in determining whether the group health plan or Medicare is the primary payer. In the absence of Employer-provided employee counts, the Center for Medicare and Medicaid Services (CMS) requires that the Employer s group health plan coverage be considered primary to Medicare. Please complete this form, sign, date, and return to BCBSTX as soon as possible. Employer Name Legal Name of Company: Employer Identification Number (EIN): Physical Address (number & street), City, State, ZIP: Account Number(s): (To be completed by BCBSTX) New BCBSTX clients please check the correct box Group Number(s): (To be completed by BCBSTX) The client was not in business during the preceding calendar year The client was in business during the preceding calendar year Do you have any affiliates or subsidiaries? Yes No If yes, list name of each: IMPORTANT NOTE: Some of the following responses are based on the current calendar year, while others are based on the preceding year. Unless making an update or error correction, please use the year of your requested Contract Effective Date as 'current year' when answering the following questions. For example, if your requested Contract Effective Date is December 1, 2009 base your current year answers on Or, if your requested Contract Effective Date is January 1, 2010 base your current year answers on Please indicate the current calendar year for which the form is being completed: If there have not yet been 20 weeks in the current calendar year, base your answer on current employee count. Understand that you are obligated to notify BCBSTX if and when your status changes. 1. In the year immediately prior to the current calendar year did you file a separate federal tax return that is not consolidated with another individual or entity? If you are not required to file a federal tax return, please check N/A 2. How many employees did all the entities on the preceding calendar year s tax return have on the payroll (whether fulltime, part-time, seasonal, or partners) during the preceding calendar year? Enter number of employees. Yes No (# of employees) 3. During the current year, are you part of a multi-employer group health plan? The term "multi-employer group health plan" means any trust, plan, association or any other arrangement made by one or more employers or by employers and unions to offer, contribute to, sponsor, or directly provide health benefits. Yes No 4. Did you have 20 or more (full-time, part-time, seasonal, or partners) total employees for each working day in each of 20 or more calendar weeks in the current or preceding calendar year? Check Yes or No for both the current and preceding calendar years If you checked Yes for the current calendar year, and the threshold was met during the current year, please check this box and enter the date the threshold was met in the following space. / /. If you check No for the current year and your answer changes to Yes at any time, you must promptly notify BCBSTX by completing a new EAF, checking this box and entering the date the threshold was met in the space above. 5. If you are currently or were during the preceding year part of a multi-employer group health plan (as defined in #3), did any one employer that is part of the multi-employer group health plan have 20 or more (full-time, part-time, seasonal, or partners) total employees for each working day in each of 20 or more calendar weeks in the current or preceding calendar year? If you answered Yes to #3, then check Yes or No for both the current and preceding calendar years. If you answered No to #3, then check Yes or No for the preceding calendar year only. 6. Did you have 100 or more (full-time, part-time, seasonal, or partners) total employees on 50 percent or more of your business days during the preceding calendar year? Current year Yes No Preceding year Yes No Current year Yes No Preceding year Yes No 7. If you are part of a multi-employer group health plan (as defined in #3), did any one employer that is part of the multiemployer group health plan have 100 or more (full-time, part-time, seasonal, or partners) total employees on 50 percent or more of your business days during the preceding calendar year? Yes No I understand that BCBSTX is relying on my answer to the above questions to determine whether Medicare will be the primary payer of claims for my Medicare eligible insured(s). I certify that the answers are true to the best of my knowledge and belief. I also understand that I am responsible to promptly notify BCBSTX, as indicated above, if my answers to the above questions change because we have increased the number of employees. Yes No For Employer: Name of Authorized Company Representative (please print) Title Signature of Authorized Company Representative Date Page 12

17 PROXY The undersigned hereby appoints the Board of Directors of Health Care Service Corporation, a Mutual Legal Reserve Company, or any successor thereof ( HCSC ), with full power of substitution, and such persons as the Board of Directors may designate by resolution, as the undersigned s proxy to act on behalf of the undersigned at all meetings of members of HCSC (and at all meetings of members of any successor of HCSC) and any adjournments thereof, with full power to vote on behalf of the undersigned on all matters that may come before any such meeting and any adjournment thereof. The annual meeting of members shall be held each year in the corporate headquarters on the last Tuesday of October at 12:30 p.m. Special meetings of members may be called pursuant to notice mailed to the member not less than 30 nor more than 60 days prior to such meetings. This proxy shall remain in effect until revoked in writing by the undersigned at least 20 days prior to any meeting of members or by attending and voting in person at any annual or special meeting of members. Group No.: By: Print Signer's Name Here Group Name: Address: Signature and Title City: State: Zip Code: Dated this day of Month Year OYER ACKNOWLEDGEMENT FORM (EAF) Page 13

18 Group Enrollment Application/Change Form Please read the instructions on the inside thoroughly before completing this enrollment application/change form. EE/CHG

19 SECTION 1 GROUP ENROLLMENT APPLICATION /CHANGE FORM INSTRUCTIONS PLEASE READ THOROUGHLY BEFORE COMPLETING ENROLLMENT APPLICATION / CHANGE FORM Use a black or blue ball point pen only. Print neatly. Do not abbreviate. Check all the boxes that apply to indicate if you are a new enrollee or if you are requesting a change to your coverage. Indicate the event and date, if applicable. Complete the additional sections that correspond to your selection. New Enrollee: Complete Sections 1, 2, 3, 4, 5, 6, 7, 8, 9, and 11 where applicable. Add Dependent: Complete Sections 1, 2, 3, 4, 5, 6, 7, 8, 9, and 11 where applicable. If you are adding or enrolling a dependent due to court order, you must submit a copy of the court order or decree AND a completed Dependent Addition and Change Form for Court-Mandated Health Coverage. If student dependent coverage is part of your employer s plan and you are adding or enrolling a dependent child who is a student, you may be required to submit a completed Student Certification form. If you are applying for coverage for a disabled dependent child over the dependent age limit of your employer s plan, you are required to submit a completed Dependent Child s Statement of Disability form. A disabled dependent over the dependent age limit of your employer s plan must be certified by medical underwriting. Change Primary Care Physician (PCP) or Primary Care Dentist (PCD): Complete Sections 1, 2, 3, 4, and 11. In Section 1, please give the reason you are changing your PCP or PCD and, in Section 4, include enrollee or dependent s name, social security number, date of birth, and name and number of the new PCP or PCD. Change Address / Name: Complete Sections 1, 2, and 11. Cancel Enrollee or Dependent: Complete Sections 1, 2, 4, and 11. In Section 4 include name, social security number, and date of birth of individual(s) canceling. SECTIONS 2 & 3 SECTION 4 SECTION 5 SECTION 6 SECTION 7 SECTION 8 SECTION 9 SECTION 10 Complete all areas that apply to you. Complete all areas that apply to you and each dependent. Only those applying for HMO or POS coverage should then select a PCP for each individual to be covered. List the name of the physician and the provider number from the provider directory or Provider Finder at Be sure to check the appropriate box for a new patient. Only HMO Blue Texas members that are applying for certain dental plans are required to select a Primary Care Dentist (PCD). ATTENTION FEMALE MEMBERS: In selecting your PCP, remember that your PCP s network may affect your choice of an OB/GYN. You have the right to receive services from an OB/GYN without first obtaining a referral from your PCP. However, for HMO members, the OB/GYN from whom you receive services must belong to the same physician practice group or independent practice association (IPA) as your PCP. This is another reason to make certain that your PCP s network includes the specialists particularly the OB/GYN and hospitals that you prefer. You are not required to designate an OB/GYN. You may elect to receive OB/GYN services from your PCP. Complete this section if your employer is offering life insurance coverage. Complete this section unless you are applying for HMO or In-Hospital Indemnity coverage. Complete this section if you or any dependent have other health care coverage through an employer (group coverage) that will not be cancelled when the coverage under this application becomes effective. Complete this section if you or any of your dependents are covered by Medicare. Complete this section if you are applying for coverage for a disabled dependent child over the dependent child age limit of your employer s plan. A disabled dependent must be certified by medical underwriting and a completed Dependent Child s Statement of Disability form must be submitted with this enrollment application. Complete this section if you are declining health coverage for yourself and your dependents. Anyone declining coverage for any reason should complete Section 10, not just those declining because of other coverage. IMPORTANT NOTICE DECLINATION OF HEALTH COVERAGE If you are declining enrollment for yourself or your dependents (including your spouse) because of other health care coverage, you may, in the future, be able to enroll yourself or your dependents in the plan provided you request enrollment within 31 days after your other coverage ends. In addition, if you have a new dependent as a result of a marriage, birth, adoption or becoming a party in a suit for adoption, you may be able to enroll yourself and your dependents provided that you request enrollment within 31 days after the marriage, birth, adoption or suit for adoption. SECTION 11 Sign your name and date the enrollment application, if you agree to the conditions set forth in this section. Your enrollment application should be submitted to your employer s Enrollment Department, who will then submit your form to: Group Accounts Dept. P. O. Box Dallas, TX Forms referenced above may be obtained by accessing the BCBSTX website at from your Marketing Service Representative, or from your employer. If you have any questions, please contact your Marketing Service Representative. EE/CHG

20 H Group # Section # Dept # Social Security Number ENROLLMENT APPLICATION/CHANGE FORM Group # Section # Dept # Category SECTION 1 ENROLLMENT EVENTS PLEASE CHECK ALL THAT APPLY IF YOU ARE DECLINING COVERAGE, COMPLETE SECTIONS 2 AND 10 ONLY. New Enrollee Add Dependent Add Coverage: Health Dental Cancel Enrollee Cancel Dependent Are you applying as a result of a Special Enrollment Term Life Dependent Life List names of those canceling in Section 4 below Event? Yes No If yes, select Short Term Disability (STD) Event: Divorce Death Event: Marriage Birth, Adoption, Suit for Adoption Long Term Disability (LTD) Terminated Employment Court Order (see instructions) Change Primary Care Physician (PCP) Other Loss of Other Coverage(provide Certification of Coverage) Reason: Other (Explain): Indicate Event Date: / / Change Primary Care Dentist (PCD) Reason: Cancel Coverage: Health Dental Term Life Dependent Life STD LTD Indicate Event Date: / / Change Address/Name SECTION 2 PLEASE TELL US ABOUT YOURSELF COMPLETE EVEN IF DECLINING COVERAGE Last Name First Name MI (opt) Suffix Date of Birth Social Security Number / / Mailing Address - Street - Apt# City State Zip Address (opt) Male Female Business Phone # Home Phone # Name of Employer Date of Employment Do you usually work at least 30 hours a week for this employer? / / Yes No Eligibility Status: Active Employee Retired Employee - Date of Retirement: COBRA Continuation Continuation of Group Coverage (insured plans only) Dependent Continuation of Group Coverage (insured plans, only) SECTION 3 SELECT YOUR COVERAGE PLEASE CHECK ALL THAT APPLY Health (select one) PPO HMO BlueEdge HCA BlueEdge HSA HMO Consumer Choice Plan (small group only) PPO Consumer Choice Plan (small group, only) Other: Plan #, if known: Enrollees (select one) Employee Only Employee /Spouse Employee /Child(ren) Family I am not applying for health coverage Dental Yes No Plan #, if known: Enrollees (select one) Employee Only Employee /Spouse Employee /Child(ren) Family I am not applying for dental coverage Complete only if you are applying for HMO coverage: Primary Language: Check here to request a Spanish Member Handbook Do you have a disability affecting your ability to communicate or read? Yes No If Yes, describe special communication materials needed: SECTION 4 COVERAGE OPTIONS SELECT A PCP FOR HMO OR POS ONLY. SELECT A PCD FOR HMO BLUE TEXAS DENTAL OPTION ONLY. Employee/Enrollee s Name PCP Name PCP No. New Patient? PCD Name PCD No. New Patient? Y N Y N Dependent s Name Husband Wife Dependent s PCP Name PCP No. New Patient? Dependent s PCD Name PCD No. New Patient? Y N Y N Dependent s Social Security No. DOB (Mo Day Yr) Home Address, if different No. and Street Name City State Zip / / Dependent s Name Son Daughter Dependent s PCP Name PCP No. New Patient? Dependent s PCD Name PCD No. New Patient? Y N Y N Dependent s Social Security No. DOB (Mo Day Yr) Home Address, if different No. and Street Name City State Zip / / Dependent s Name Son Daughter Dependent s PCP Name PCP No. New Patient? Dependent s PCD Name PCD No. New Patient? Y N Y N Dependent s Social Security No. DOB (Mo Day Yr) Home Address, if different No. and Street Name City State Zip / / Dependent s Name Son Daughter Dependent s PCP Name PCP No. New Patient? Dependent s PCD Name PCD No. New Patient? Y N Y N Dependent s Social Security No. DOB (Mo Day Yr) Home Address, if different No. and Street Name City State Zip / / SECTION 5 GROUP TERM LIFE, ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D), AND DISABILITY INSURANCE COVERAGES Employee Occupation/Job title: Wage rate $ per hour week month year Group Basic Term Life & AD&D I do not apply I do apply Amount $ Group Dependents Life I do not apply I do apply Group Supplemental Life I do not apply I do apply Employee election: $ Spouse election: $ Child election: $ Short Term Disability (STD) I do not apply I do apply Long Term Disability (LTD) I do not apply I do apply Primary First Name Initial Last Name Relationship Date of Birth Social Security No. Beneficiary Contingent First Name Initial Last Name Relationship Date of Birth Social Security No. Beneficiary EE/CHG A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Fort Dearborn Life Insurance Company, a Member of the Preferred Financial Group

21 Last Name: Social Security Number: H Group # SECTION 6 PREVIOUS COVERAGE INFORMATION DO NOT COMPLETE IF APPLYING FOR HMO OR IN-HOSPITAL INDEMNITY COVERAGE In order to receive credit for pre-existing condition waiting periods, you must provide information about the last 12 months of coverage (18 months if new/current coverage is selffunded) for you and any dependents listed. If you have a certificate of prior coverage, please attach a copy to this enrollment application. (If more than one plan was in effect, or if information is different for dependents, attach additional pages.) If Medicare, please complete the Medicare Coverage Information in Section 8. List names of every individual covered: Name of Primary Enrollee Date of Birth Male Relationship to Applicant Group or Policy No. ID Number / / Female Self Spouse Dependent Employer s Name: Employment Date / / Type of Coverage Type of Policy Name and address of other insurance company, TPA, HMO: Effective Date / / Health Self Family Will Coverage be Continued? Yes No Dental Employee/Spouse If No, Expected Cancel Date / / Employee/Child SECTION 7 OTHER COVERAGE INFORMATION Complete this section only if you or any of your dependents have other health and / or dental coverage that will not be cancelled when the coverage under this application becomes effective. List names of each individual covered: Type of Coverage Group Coverage Name and Address of Other Health Care Company Health Dental Yes No Name of Policyholder Date of Birth Male Relationship to Applicant Type of Policy / / Female Self Spouse Dependent Self Two Person Family ID Number Employment Date Effective Date of Coverage Group or Policy Number Employer s Name SECTION 8 MEDICARE COVERAGE INFORMATION Name of person covered: Medicare Part A (hospital) Start Date: End Date: Medicare HIC# (from ID card): Medicare Part B (medical) Start Date: End Date: Month/Day/Year Month/Day/Year Month/Day/Year Month/Day/Year Medicare Part D (prescription drugs) Start Date: End Date: If BCBSTX is not the Medicare Part D carrier, please provide name and address of the carrier: Name: Month/Day/Year Month/Day/Year Address: City State Check reason for Medicare eligibility: Entitled age Entitled disability End-stage renal disease Disability and current renal disease Name of person covered: Medicare HIC# (from ID card): Medicare Part A (hospital) Medicare Part B (medical) Start Date: End Date: Start Date: End Date: Month/Day/Year Month/Day/Year Month/Day/Year Month/Day/Year Medicare Part D (prescription drugs) If BCBSTX is not the Medicare Part D carrier, please provide name and address of Start Date: End Date: the carrier: Name: Month/Day/Year Month/Day/Year Address: City State Check reason for Medicare eligibility: Entitled age Entitled disability End-stage renal disease Disability and current renal disease SECTION 9 DISABLED DEPENDENT Name of disabled dependent Nature of disability Has disability been diagnosed as permanent? Yes No If temporary, how long is dependent expected to remain disabled? Is dependent unable to work due to the disability? Yes No If disabled child is over the dependent age limit of your employer s plan, please attach a completed Dependent Child s Statement of Disability form. SECTION 10 DECLINATION OF HEALTH COVERAGE This is to certify the available coverage has been explained to me. I have been given the opportunity to apply for the coverage offered to me and my eligible dependents and have voluntarily elected to decline the coverage as indicated below. If I desire to apply for coverage at a later date, I understand there may be a delay in the effective date of the coverage as well as a pre-existing condition waiting period. Employee Reason for declining: Other Group Coverage Medicare Medicaid Other, explain: Spouse Reason for declining: Other Group Coverage Medicare Medicaid Other, explain: Child(ren) Reason for declining: Other Group Coverage Medicare Medicaid Other, explain: SECTION 11 COVERAGE CONDITIONS I am an employee of the Employer named in this Enrollment Application. I am eligible to participate in the coverage(s) afforded by my Employer s plan, which is either underwritten or administered by Blue Cross and Blue Shield of Texas (BCBSTX) or Fort Dearborn Life Insurance Company (FDL). On behalf of myself and any dependents listed on this Enrollment Application, I apply for those coverage(s) for which I am eligible. I state that the information given on this Enrollment Application is true and correct. I understand and agree that any incorrect statements material to the risk and knowingly made by me will invalidate my coverage(s). Only those coverage(s) and amounts for which I am eligible will be available to me. I understand that if this Enrollment Application is accepted, the coverage(s) will become effective in accordance with the provisions of the Contracts(s)/Plan(s). I understand that the Health coverage for which I am applying may have a pre-existing condition exclusion waiting period. I agree that my Employer acts as my agent. I authorize necessary payroll deduction by my Employer, if any, to cover the cost of my coverage(s). I understand that my participation in the coverage(s) is subject to any future amendment. I also understand that all notices given to my Employer are binding upon me. Applicant s Signature Date EE/CHG

22 TIPS for Submitting New Regulated Small Groups (groups with 2-50 eligible employees) Blue Cross and Blue Shield of Texas is committed to providing excellent service. The following information provides tips we believe you will find helpful as you prepare to submit enrollment information for new small groups. Qualifying the candidate 1. Is the business a candidate for small employer group coverage? Use this formula to determine if a business is a candidate for small employer group coverage: Count the total employees on the payroll + New hires Part-time employees (work less than 30 hours per week) Seasonal employees Temporary employees Employees with other group coverage (do not subtract those who have an individual health policy) Terminated employees = Result A result of 2 to 50 indicates the business is a candidate for small employer group coverage. Note: If the result is greater than 51, the group may not qualify for small group coverage. Please contact us at (800) to discuss other coverage options. 2. Will the required number of eligible employees enroll in the small group coverage plan? At least 75 percent of eligible employees are required to enroll in the small group coverage plan. Use the following formula to determine if the participation requirement will be met: Count the total employees on the payroll + New hires Part-time employees Seasonal employees Temporary employees Employees declining due to having other group coverage Terminated employees Employees serving an eligibility waiting period = Result Result multiplied by.75 equals the number of employees who must enroll. Report this as a whole number and round down. Example 1: 75 Total employees on payroll + 2 New hires (not yet on payroll) 30 Part-time employees 0 Seasonal employees 0 Temporary employees 1 Employees with other group coverage 2 Recently terminated employees = 44 The result of 44 is between 2 and 50 so the business is a candidate for small employer group coverage. Example 2: 75 Total employees on payroll + 2 New hires (not yet on payroll) 30 Part-time employees 0 Seasonal employees 0 Temporary employees 1 Employee declining due to having other group coverage 2 Recently terminated employees 6 Employees serving an eligibility waiting period = multiplied by.75 = is the minimum number of employees who must enroll in the small employer group health plan.

23 Submitting documentation Submitting documentation is an important step in the enrollment process. It is very important that all items are completed. Submitting incomplete documentation results in processing delays, and can result in members not receiving identification cards as quickly as possible. Please screen all documents to ensure they are complete prior to submitting them to BCBSTX. Here are some additional tips: 1. Small Group Employer Application (SGEA) Each field must be completed. Page 1 asks for the legal name of the company. The legal company name provided on this document should be consistent with the company name on all other documentation provided. An Assumed Name Certificate is needed if the company name on proof of business documentation does not match the legal company name provided on page 1 of the Small Group Employer Application. Question #8 (page 2) and question #4 on the Medicare Secondary Payer form address the total number of employees. Please ensure these two responses are consistent with each other. Please ensure choice of network (page 3) matches the plan selected on the Signed Small Group Proposal. Medical questionnaire (page 5) must be initialed by the group executive and agent. An employer group executive may be aware of the group having an ERISA Plan Year that is different from their requested health care contract effective date. If that is the case, please indicate the ERISA Plan Year at the bottom of page 6. TIPS 2. Employee Enrollment Applications Each field must be completed. Agents should review Employee Applications and obtain any missing information prior to submitting them to BCBSTX. Verify section 3 is completed correctly if applying for dual plans. Check sections 3, 4 & 10 for consistency. Verify PPO network matches network selection on the Employer Application and Signed Small Group Proposal. All fields in section 6 must be completed to receive credit for prior coverage. Ensure section 10 (Reason for Declining) is completed when appropriate. When applicable, two forms are needed: Continuation of Coverage-COBRA Application and the routine Employee Group Enrollment Application. 3. Signed Small Group Proposal To further explain what is meant by Signed Small Group Proposal, please submit the page from the proposal that the Group Administrator signs, dates and indicates the plan(s) selected.

24 4. Proof of Business Examples of acceptable forms of proof of business: Most current Texas Wage & Tax Report including cover page (commonly referred to as TWC) OR All pages of Articles of Incorporation filed with the state OR All pages of Articles of Organization filed with the state OR All pages of Certificate of Organization filed with the state OR All pages of Certificate of Limited Partnership filed with the state OR All pages of Limited Liability Company organizational documents filed with the state Other documents may be accepted for proof of business. Those listed here are examples of commonly used proof of business documentation. If you have questions concerning the documentation that you have, please contact us at (800) to discuss. 5. Proof of Wages and Texas Supplemental Employee Verification Form Examples of acceptable forms of proof of wages: If providing a current Wage & Tax Report (commonly referred to as TWC) it demonstrates proof of wages. Employees who are not on the Wage & Tax Report should be listed on the Texas Supplemental Employee Verification Form. OR Payroll Reports. (must show number of employees for each month in the prior quarter need 3 months) OR W-2s on existing employees and W-4s on new hires. (Boxes 8 and 10 on each W-4 are needed) 1099 Forms are an acceptable proof of wages for contract employees. TIPS Other documents may be accepted for proof of wages. Those listed here are examples of commonly used proof of wages documentation. If you have questions concerning the documentation that you have, please contact us at (800) to discuss. 6. Medicare Secondary Payer Form Each field must be completed. Question #4 on this form and question #8 on the Small Group Employer Application address the total number of employees. Please ensure these two responses are consistent with each other. Questions? Contact us at (800) Ensure Group Meets 75 Percent Participation Requirement On any employee listing (for example Wage & Tax report) please indicate employees that are part-time, seasonal and/or terminated. 8. Premium Payment Check A check from the small employer group business should be made payable to Blue Cross and Blue Shield of Texas, or BCBSTX, for the health/dental premium. When life coverage is purchased, a separate check for the premium payment should be made out to Fort Dearborn Life, or FDL. Temporary checks are not preferred but will be accepted if necessary. Please provide an explanation if the company s address on the check is out of state.

25 9. Proxy This is a form letter found on our Web site that is completed by employers so that the Health Care Service Corporation Board of Directors can act on the member s behalf at board meetings. Sole Proprietorship A Sole Proprietorship has one owner. If the spouse of the owner is an employee, proof of wages is needed for the spouse and the spouse would not be listed as an owner on the following documents. TIPS One form of proof of business is needed. Examples of acceptable forms are: Most current Wage & Tax Report, including cover page (commonly referred to as TWC) OR Profit or Loss from Business (IRS Form-Schedule C) OR Net Profit From Business (IRS Form-Schedule C-EZ) OR Self Employment Tax Schedule SE (IRS Form-Schedule SE) One form of proof of wages is needed. Preferred Employer Organization (PEO) The PEO/Staff Leasing Company must be licensed in the state of Texas. Client group (employer) must be able to verify employees for their group. The Wage & Tax Report or W-4s and W-2s should include the name of the client group applying for coverage. If Wage & Tax Report, W-2s or W-4s are not available, a copy of billing to the client group identifying employees must accompany the paperwork. This billing must identify the client group. The client agreement must support the information we are being provided. Decision-maker cannot be the PEO. The contract and signature must be with the owner or decision-maker of the client group. Medical information must come from the client group, not the PEO. Need copy of PEO/Staff Leasing Company contract showing the group to be insured as the client group. One form of proof of wages is needed. Blue Cross and Blue Shield of Texas Small Business Service Center 1201 E. Campbell Road Richardson, TX (800) A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association