Fill and Sign the Accountants Professional Liability Insurance Application Herbert H Form

Supplemental Enrollment Information Form Delaware HB 446 Title 18, Section 3354 - Health Insurance Coverage for Children of Insureds Aetna Health Inc./Aetna Life Insurance Company/Corporate Health Insurance Company A. Group & Employee Information Group Name Group Number/Control Number Employee Name Aetna Member ID Number B. Type of Activity (see Important Explanatory Information below) Change - Check all that apply Effective Date / / / / Add dependent over the limiting age, but less than 24 Remove dependent over the limiting age, but less than 24 Reason(s): Continuation of Coverage pursuant to Title 18, Section 3354 Effective Date Coverage is being elected: / / During an Open Enrollment Within 30 days after eligibility for other reasons Within 30 days prior to or following the attainment During special 12-month enrollment which begins of limiting age 6/1/2007 and ends 5/31/2008 Billing: (Aetna will bill over-age dependents directly and enrollees will remit the premium directly to Aetna.) X Direct bill dependent (add billing address, required even if the same as the employee’s address): Street, Apt. Number: City, State, ZIP Code: C. Over-age Dependent Information Name (Last, First, MI) Sex Birthdate (MM/DD/YYYY) M Yes Other Health Coverage: Primary Physician Office ID Number: Current Patient: Yes Previous Coverage: Yes F / Social Security Number / No Other Rx Drug Coverage: Yes No No Ob/Gyn Physician Office ID Number: Current Patient: Yes No N/A If yes, provide the following information AND submit a copy of the certificate of Creditable Coverage that was issued by the previous carrier, if available: No Effective date of prior coverage: Name of prior carrier: / / / / Termination date of prior coverage: Prior plan number: D. Signature I have read the Important Information below and agree to the conditions of enrollment. The information supplied in this application is true and complete. Employee Date Dependent Date Important Information Regarding Cost-Sharing Limitations The employee must continue coverage in order for the dependent to be covered in addition to the additional applicable eligibility criteria. Coverage for the dependent will be issued as stand-alone coverage. All cost-sharing requirements and limitations will apply and will not be combined with the employee’s policy. Consequently, covered expenses incurred by the over-age dependent will not contribute to family deductibles and out-of-pocket maximums, nor will family incurred expenses contribute to the over-age dependent’s deductibles or out-of-pocket maximums. IMPORTANT EXPLANATORY INFORMATION An adult child may request to continue as a dependent on his or her parent’s coverage even after the child reaches the limiting age under the terms of the policy if the adult child: • is less than 24 years of age; • is unmarried; • has no dependents of his or her own; • is a resident of Delaware or is enrolled as a full-time student at an accredited public or private institution of higher education; and • is not provided coverage as a named subscriber, insured, enrollee, or covered person under any other group or individual health benefits plan, group health plan, church plan, or entitled to Medicare. An adult child may make written request to continue as a dependent on his or her parent’s coverage either: • within 30 days prior to or following the termination of coverage at the specific age provided in the contract’s language; • within 30 days after meeting the requirements for dependent status, when coverage for the dependent had previously terminated; • during the open enrollment period for the group of which the parent is a member, when the dependent meets the requirements for dependent status during the open enrollment period. (Dependent child will be enrolled in same coverage as that of the parent(s).) In addition, adult children who reached the limiting age under the parent’s coverage prior to June 1, 2007 may make an enrollment request at any time from June 1, 2007 through May 31, 2008. The adult child or covered employee will be required to pay up to 102% of the cost of the dependent premium. GR-68189-1 (4-07) DE R-POD