Submission of 2014 Benefit Enrollment Information

Please review and make any necessary changes:

First Name: <FIRSTNAME>

Last Name: <LASTNAME>

Date of Birth: <DOB>

Gender: <GENDER>

Street Address: <ADDRESS>

City: <CITY>

State: <STATE>

Zip: <ZIP>

Home Phone Number: <HOMEPHONE>

Health Insurance Preexisting Condition Exclusion Rules

This plan imposes a preexisting condition exclusion. That means that if you have a medical condition before coming to our plan, you might have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis, care, or treatment is recommended or received within the 6-month period prior to your enrollment date. Generally, this 6-month period ends the day before your coverage becomes effective. The preexisting condition exclusion does not apply to pregnancy nor to a child who is enrolled in the plan or who has creditable coverage within 30 days after birth, adoption, or placement for adoption.

This exclusion may last up to 12 months from your first day of coverage or, if you were in a waiting period, from the first day of your waiting period. However, you can reduce the length of this exclusion period by the number of days of your prior "creditable coverage." Most prior health coverage is creditable coverage and can be sued to reduce the preexisting condition exclusion if you have not experienced a break in coverage of at least 63 days. To reduce the 12-month exclusion period by your creditable coverage (HIPAA Certificates) you have. If you do not have a Certificate, but you do have prior health coverage, we will help you obtain one from your prior plan or issuer. There are also other ways that you can show that you have creditable coverage. Please contact us if you need help demonstrating creditable coverage.

Special Enrollment Provision

Loss of Other Coverage.

If you decline enrollment for yourself or for an eligible dependent (including your spouse/partner) while other health insurance or group health plan coverage is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward you or your dependents’ other coverage). However, you must request enrollment within 31 days after you or your dependents’ other coverage ends (or after the employer stops contribution toward the other coverage).

New Dependent by Marriage, Birth, Adoption, or Placement for Adoption.

In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and any other eligible dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.



I understand that if I have made any false statements or misrepresentations or have failed to disclose or concealed any material fact, benefits may be denied and/or coverage may be voided. I agree that any surgeon, physician, dentist, pharmacist, nurse, hospital or health care facility may furnish the diagnosis for any history of any past, present, or future treatments or conditions of all persons named herein. I agree, upon request, to furnish all information required to administer the health care plan. I hereby authorize my employer to make deductions from my wages for the cost of my benefits, if required. For benefits offered on a pre-tax basis, I understand that if I do not want my wages reduced on a pre-tax basis, I will need to contact my employer in writing. I understand that any insurance applied for after my original eligibility date and/or in excess of the guaranteed issue amount will not begin until approved.

For residents of all states except Florida, New Jersey, New York, Pennsylvania, Utah, Vermont, Virginia and Washington; WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or knowing that he is facilitating commissions of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information when filing an insurance application or a statement of claim for payment of a loss or benefit commits a fraudulent insurance act, is/may be guilty of a crime and may be prosecuted and punished under state law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison, In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant or if the applicant conceals, for the purpose of misleading, information concerning any fact material thereto.

Receipt of accelerated death benefits may affect eligibility for public assistance programs and may be taxable. Please contact your personal tax advisor for further information. There is no administrative fee to accelerate death benefits. The accelerated amount is not discounted.