Instructions. 1. Your employer will complete section A. 2. Complete sections B through F.

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Instructions 1. Your employer will complete section A. 2. Complete sections B through. 3. If you are electing medical, complete the section entitled EDICAL OPTIONS. 4. Read the information on the back of the enrollment/change form. 5. Sign and date the enrollment/change. We look forward to having you as our customer. CAT. #EW08873

Employer: Complete Section A Employee: Complete Section B- Enrollment/Change orm A OPEN ENROLL CHANGE NEW ENROLL REINSTATE B SINGLE ARRIED / / SEPARATED DIVORCED WIDOWED EECTIVE DATE O CHANGE ADD/CHANGE/CANCELLATION (/DD/CCYY) / / EPLOYER NAE Kenai Drilling Limited Administered by Cigna Health and Life Insurance Company DATE O HIRE (/DD/CCYY) / / PLAN NUBER 622225 SUBGROUP TYPE O CHANGE Add (s) * Demographics PCP Change Retirement CLASS * List Name(s) in Section C COBRA Continuation Other Qualifying Event Date: / / C EPLOYEE NAE (Last) (irst) SOCIAL SECURITY NUBER - - EPLOYEE DATE O BIRTH (/DD/CCYY) HOE PHONE EAIL ADDRESS / / ( ) ADDRESS (Street) (City) (State) (Zip Code) YES, I WOULD LIKE COVERAGE OR YSEL AND Y DEPENDENTS. (Specify last name if different from yours) Employee Last Name irst Name Social Security Number Date of Birth (/DD/CCYY) Gender H e i g h t W e I g h t ADDITIONAL INORATION- * DEPENDENTS If totally disabled prior to age 26, attach proof of disability for eligibility review. s are covered under the medical plan to age 26. Proof of student status may be required for dental and/or vision coverage. **PCP ID is required when the edical Option selected below is Cigna Sureit. If a PCP is not selected during enrollment one will be assigned. Otherwise PCP is optional. D EDICAL OPTIONS: Open Access Plus/ OAP IN Open Access Plus/ OAP Open Access Plus/ HSA Coverage Selection ed ed ed ed ed ull- Time Student? Decline Coverage CAT. #EW08873

E OTHER HEALTHCARE COVERAGE: Do you or your dependents have other health insurance under a group plan, HO, or edicare? If yes, please provide the following: EDICARE OTHER INSURANCE NAE O PERSON COVERED SOCIAL SECURITY NUBER EECTIVE DATE Part A Part B EDICAID CARRIER - - / / - - / / The information provided above is true and correct to the best of my knowledge, and I accept the provisions on the reverse side of this form which I have read and understand. By my signature below, I acknowledge that I have read and understand the disclosure in this Enrollment/Change orm. I authorize the required payroll deduction for contributory benefits. I also represent that all information shown on this Enrollment/Change orm is correct. I understand that I will not be individually denied coverage or be individually charged different rates as a result of my answers. However, if I knowingly provide false information on this Questionnaire, I understand and agree that it may affect the payment of claims or result in termination of my/or my dependent(s) coverage. EPLOYEE SIGNATURE / DATE 10SA0.03 CAT. #EW08873Rev 07/17

PROVISIONS Cigna Dental PPO plans are administered by CHLIC, with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. I agree, for myself and my covered dependents, that, in the event any health services provided are the primary responsibility of any other party by way of other group health coverage or by the act or omission of another person, I will fully inform the health plan and will execute such assignments, liens or other documents which may be necessary to enable the health plan to recover the value of the services provided. I further agree that in the event I or any of my covered dependents collect benefits or damages from any other party who has primary responsibility for services provided by the health plan, I will immediately reimburse the health plan to the extent permitted by state law. RAUD WARNING Any person who, knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act. AUTHORIZATION TO DEDUCT CONTRIBUTIONS I authorize deductions from my earnings of the required contributions, if any, toward the cost of the coverage. This authorization applies only if employee contributions are required. SPECIAL PROVISIONS OR EPLOYERS WITH SECTION 125 PLANS By allowing an individual to enroll in the health plan, other than during the open enrollment period, Cigna Health and Life Insurance Company and its affiliates do not waive any terms of its contract. urther, by allowing an individual to enroll in the health plan, other than during an open enrollment period, Cigna Health and Life Insurance Company and its affiliates do not thereby express any opinion regarding the appropriateness of the change under Section 125 of the Internal Revenue Code or the terms of the employer s Section 125 Plan. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company and Cigna Dental Health, Inc. and its subsidiaries. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 2018 Cigna

DISCRIINATION IS AGAINST THE LAW edical coverage Cigna complies with applicable ederal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact customer service at the toll-free number shown on your ID card, and ask a Customer Service Associate for assistance. If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by sending an email to ACAGrievance@Cigna.com or by writing to the following address: Cigna ndiscrimination Complaint Coordinator PO Box 188016 Chattanooga, TN 37422 If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to ACAGrievance@Cigna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509, HHH Building Washington, DC 20201 1.800.368.1019, 800.537.7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., Cigna Health anagement, Inc., and HO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. or current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711). ATENCIÓN: Si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711). 896375a 05/17 2017 Cigna.

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