Application for Coverage

Application for Coverage Products issued by: Capital Advantage Assurance Company Capital Advantage Insurance Company Keystone Health Plan Central Subsidiaries of Capital BlueCross, Independent Licensee of the BlueCross BlueShield Association Who can use this application? You can use this application for anyone who needs health insurance or dental insurance. Apply faster online at capbluecross.com What happens next? If you apply by paper, send your complete, signed application and premium payment information to: Capital BlueCross PO Box 772612 Harrisburg, PA 17177-2612 OR Fax to: 717.541.6667 Email to: cbciadp@capbluecross.com Your application will be processed and you will receive your enrollment materials. Get help with this application. Phone: Call our Sales department at 1.800.451.1181 In Person: Visit our Retail Store located at: 2845 Center Valley Parkway, Suite 404/409, Center Valley, PA 18034 Information is private. We ll keep your information private as required by law. NEED HELP WITH YOUR APPLICATION? Call us at 1.800.451.1181, or visit us at capbluecross.com. Para obtener una copia de este formulario en Español, llame 1.800.451.1181. Capital Advantage Insurance Company, Capital Advantage Assurance Company, and Keystone Health Plan Central, Capital BlueCross companies, do not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations. Page 1 of 10

Applicant Details Tell us about yourself. Effective Date: Request type: New application New application Child Only Policy Add dependent Remove dependent Dental application (if dental only, please skip medical selection section on pages 5 and 6) Cancel Policy Special enrollment reason: Birth/Adoption Marriage Loss of Coverage Subscriber I.D. #: Step 1: Subscriber Last Name First Name Middle Initial Suffix Physical Address Address Line 2 City State Zip Code County Mailing Address (if different from physical address) Address Line 2 City State Zip Code County Phone Number Other Phone Number ( ) ( ) I would like to get information about this application by: Email: Email Address: Text: Cell Phone Number: ( ) Preferred Language Spoken (if not English) Preferred Language Read (if not English) Social Security Number Gender: Date of Birth (MM/DD/YYYY) Male Female / / Tobacco User: (Tobacco use is considered to be four or more times per week, and should be answered only if the individual is 18 years or older.) If yes, date tobacco was last used (MM/DD/YYYY) / / Now, tell us who else needs insurance. Page 2 of 10

Dependents Tell us about anyone who needs insurance. Attach additional sheets of paper if you need to. Step 2: Spouse Last Name First Name Middle Initial Suffix Social Security Number Gender: Date of Birth (MM/DD/YYYY) Male Female / / Does this person live at the same address as you? Yes No If no, list address: Relationship to you? Tobacco User: (Tobacco use is considered to be four or more times per week, and should be answered only if the individual is 18 years or older.) If yes, date tobacco was last used (MM/DD/YYYY) / / Step 2: Dependent 1 Last Name First Name Middle Initial Suffix Social Security Number Gender: Date of Birth (MM/DD/YYYY) Male Female / / Does this person live at the same address as you? Yes No If no, list address: Relationship to you? Disabled Dependent: Certification will be required. Tobacco User: (Tobacco use is considered to be four or more times per week, and should be answered only if the individual is 18 years or older.) If yes, date tobacco was last used (MM/DD/YYYY) / / Page 3 of 10

Dependents (continued) Step 2: Dependent 2 Last Name First Name Middle Initial Suffix Social Security Number Gender: Date of Birth (MM/DD/YYYY) Male Female / / Does this person live at the same address as you? Yes No If no, list address: Relationship to you? Disabled Dependent: Certification will be required. Tobacco User: (Tobacco use is considered to be four or more times per week, and should be answered only if the individual is 18 years or older.) If yes, date tobacco was last used (MM/DD/YYYY) / / Step 2: Dependent 3 Last Name First Name Middle Initial Suffix Social Security Number Gender: Date of Birth (MM/DD/YYYY) Male Female / / Does this person live at the same address as you? Yes No If no, list address: Relationship to you? Disabled Dependent: Certification will be required. Tobacco User: (Tobacco use is considered to be four or more times per week, and should be answered only if the individual is 18 years or older.) If yes, date tobacco was last used (MM/DD/YYYY) / / Page 4 of 10

Product Selection Select Medical Product Drug benefits and pediatric vision benefits are always included with your medical plan selection. Our products do not include pediatric dental coverage. To purchase a medical plan, you must have purchased an exchange-certified stand-alone pediatric dental plan. (Exchange-certified, stand-alone dental plans are offered on page 7 of this application.) Please provide the name of the company that is providing this coverage, together with the name of the plan. Name of Company: Name of Plan: I hereby certify that I have and will continue to maintain the exchange-certified stand-alone pediatric dental plan indicated above for as long as I maintain enrollment in the product selected below. Catastrophic Option Bronze Options Silver Options Gold Options Platinum Options HMO 6350.0 1 HMO 5500.0 1 HMO 4500.0 1 HMO 3000.0 1 HMO 0.0.10 1 HMOIJ621 ] HMOIJ601 ] HMOIJ605 ] HMOIJ597 ] HMOIJ617 ] PPO 5500.0 2 PPO 4500.0 2 PPO 3000.0 2 PPO 0.0.10 2 PPOIJ279 ] PPOIJ280 ] PPOIJ278 ] PPOIJ283 ] HMO 3500.0 1 HMOIJ609 ] HMO 1000.0 1 HMOIJ593 ] 1 HMO Issued by Keystone Health Plan Central 2 PPO Issued by Capital Advantage Assurance Company PPO 3500.0 2 PPOIJ281 ] HMO 2500.0 1 HMOIJ589 ] PPO 2500.0 2 PPOIJ276 ] HMO 2000.0 1 HMOIJ613 ] PPO 2000.0 2 PPOIJ282 ] [ CareConnect Gatekeeper PPO 3000.0 3 PGOIJ300 ] HMO 0.50 1 HMOIJ585 ] PPO 0.50 2 PPOIJ275 ] HMO 0.0 1 HMOIJ581 ] PPO 0.0 2 PPOIJ274 ] PPO 1000.0 2 PPOIJ277 ] HMO 500.0 1 HMOIJ577 ] PPO 500.0 2 PPOIJ273 ] 3 CareConnect Gatekeeper PPO issued by Capital Advantage Insurance Company Page 5 of 10

Product Selection (continued) Does the product selection you chose apply to all of the persons you identified in Steps 1 and 2? If no, please specify the product selection for each family member: Primary Applicant: Spouse: Dependent 1: Dependent 2: Dependent 3: Primary Care Physician If you or a covered person selected a medical HMO or CareConnect 3000.0 product, you are required to select a Primary Care Physician. You and each dependent can select his/her own Primary Care Physician from the Keystone Health Plan Central Provider Directory or on our website capbluecross.com. The directory or website may indicate that the physician you wish to select is available to current patients only. If you are currently a patient of that physician, please indicate that in this section of the application. If you are not currently a patient, you must select a different Primary Care Physician. Applicant s Primary Care Physician Selection Practice s Name Primary Care Physician Code # Current Patient Spouse s Primary Care Physician Selection Practice s Name Primary Care Physician Code # Current Patient Dependent 1 s Primary Care Physician Selection Practice s Name Primary Care Physician Code # Current Patient Dependent 2 s Primary Care Physician Selection Practice s Name Primary Care Physician Code # Current Patient Dependent 3 s Primary Care Physician Selection Practice s Name Primary Care Physician Code # Current Patient Page 6 of 10

Product Selection (continued) Select Dental Product We offer exchange-certified, pediatric only dental products* and dental products that cover adults and pediatrics. Healthy Dental PPO Pediatric* BPDI0107 Healthy Dental PPO Plan 1 BCDI0103 Healthy Dental PPO Plan 2 BCDI0104 Healthy Dental PPO Plan 3 BCDI0105 Dental Issued by Capital Advantage Assurance Company Healthy Dental HMO** Pediatric 702xs* BPDI0109 Healthy Dental HMO** Basic BCDI0107 * Only available for eligible individuals under the age of 19. **This plan requires the selection of a primary care dentist (PCD) from the Plan s dental HMO network. The member s PCD provides routine care and arranges or provides most other necessary services. Except for emergency services, benefits are covered only when provided or properly referred by the member s PCD, preauthorized by Capital or as stated within the dental policy. Does the dental product selection you chose apply to all of the persons you identified in Steps 1 and 2? If no, please specify the dental product selection for each family member: Primary Applicant: Spouse: Dependent 1: Dependent 2: Dependent 3: Select Vision Product Vision coverage is available to persons that enroll in our medical and/or dental products. You must be enrolled in a medical or dental product to be eligible for the vision plan. Healthy Vision Plan 1 BCVI0124 Vision Issued by Capital Advantage Assurance Company Does the vision product selection apply to all of the persons you identified in Steps 1 and 2? Note: If you selected a medical plan from us, pediatric vision benefits (under age 19) are always included with your medical plan selection. If no, please specify which person(s) the vision product is applicable to: Primary Applicant: Spouse: Dependent 1: Dependent 2: Dependent 3: Page 7 of 10

Premium Payment Payment of your first month s premium is due at time of application; please select a payment method below: Billing Method (please select one): Bill Payer (please complete additional information below) Please send me a bill. Credit Card (If paying by credit card, please go to capbluecross.com/wps/wcm/connect/cbc-public/cbc/paymypremium/paymypremiumhome to authorize payment. Please enroll me in Check It Out automatic withdraw program. (please complete additional information below) Financial Institution Information (please print) Name of Financial Institution ABA Number Name of Bank Account Bank Account Number Signature of Capital BlueCross Subscriber Account Type for Withdrawal Checking Savings Signature (if joint account) Date Signature (if account is other than subscriber s) Date Bottom of Check Please note: Notification of premium changes will be sent to the subscriber only. ABA/Transit Routing Number Account Number Please complete the following information if using Bill Payer Name on Account Name of Insured Financial Institution s Name Date Payment will be Transfered Financial Institution s Confirmation Number Producer of Record If you worked with a licensed sales agent who is appointed with Capital BlueCross or its family of companies, please have the producer complete the following section. If you worked independently, please leave this section blank. Producer (please print) Signature of Producer Name (Producer) Producer ID # Signature of Producer Name (General Agent) Producer s Email Date Page 8 of 10

Notification and Authorization Please note: If you and your spouse are applying for coverage, your spouse is considered a coapplicant and also must read and accept these conditions of enrollment, and sign and date this application for coverage below. In addition, any dependents age 18 or older for which coverage is requested must also read and accept these conditions of enrollment, and sign and date this application for coverage below. I hereby apply for the coverage indicated. I understand this application is subject to approval by Capital BlueCross. Any coverage will be subject to the terms of the contract issued to me. You must have your primary residence in the Capital BlueCross 21-county service area, which includes Adams, Berks, Centre, Columbia, Cumberland, Dauphin, Franklin, Fulton, Juniata, Lancaster, Lebanon, Lehigh, Mifflin, Montour, Northampton, Northumberland, Perry, Schuylkill, Snyder, Union, and York counties. Your medical enrollment application must be received by Capital BlueCross during the initial or annual open enrollment periods. If you qualify for a special enrollment period, your medical application must be received during your special enrollment period. If changes are indicated, Capital BlueCross is authorized to make the changes requested above to my enrollment records. I understand the effective date of the changes will be determined by Capital BlueCross. I/we verify that the information given in this enrollment application is true and correct. Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim contacting any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Applicant s Signature: Printed Name: Date: / / Coapplicant s/spouse s Signature: Printed Name: Date: / / Dependent s Signature (if age 18 or older; if under 18, parent signature required): Printed Name: Date: / / Dependent s Signature (if age 18 or older; if under 18, parent signature required): Printed Name: Date: / / Dependent s Signature (if age 18 or older; if under 18, parent signature required): Printed Name: Date: / / Representative ID (to be completed if requested by your representative) If you applied for a Child Only Policy, please complete this section: Name of Guarantor: First Name Middle Initial Last Name Title Guarantor s Home Address Address Line 2 City State Zip Code County Phone Number Relationship to Child Page 9 of 10

Replacement of Coverage Replacement of Inforce Policy Is the insurance being applied for intended to replace any other accident and health insurance currently in force? If you answered yes to the previous question, please complete the following information: Notice to Applicant Regarding Replacement If you intend to lapse or otherwise terminate existing health insurance coverage and replace it with coverage to be issued by Capital BlueCross, Capital Advantage Insurance Company, Capital Advantage Assurance Company, and Keystone Health Plan Central (Capital), please be advised of the following. Your new contract with Capital will provide a period of 10 days after receipt of the contract within which you may decide whether you desire to keep the contract. For your own information and protection, you should be aware of and seriously consider certain factors which may affect the insurance protection available to you under the new contract. 1. Health conditions which you may presently have (preexisting conditions) will be covered under the new contract as long as the treatment for which you seek coverage is a covered benefit. 2. There are no waiting periods under your new contract for coverage to be effective. 3. You may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of your present coverage. This is not only your right, but is also in your best interest to make sure you understand all of the relevant factors involved in replacing your present coverage. 4. If, after due consideration, you still wish to terminate your present coverage and replace it with new coverage, be certain to truthfully and completely answer all questions on the application. Failure to include all material medical information on your application may provide a basis for the company to deny or terminate coverage and to refund your premium as though your contract had never been in force. The above Notice to Applicant was delivered to me and read on: Date: Applicant Name (please print): Applicant Signature: Coapplicant Name (please print): Coapplicant Signature: Page 10 of 10