Fill and Sign the Bir Form 1800

MidAtlantic Small Group March 17, 2003 Aetna Introduces New Applications for Small Group Business in Pennsylvania **Now, one form for all products** (Mandatory with May 1, 2003 effective dates and forward) With the introduction of a new Employer Application and new Employee Enrollment/Change form, Aetna Small Group is once again making it easier for our brokers and clients in Pennsylvania to conduct business with us. These new forms now offer small business employers and their employees the convenience of having only one application to fill out for all Aetna Small Group products. Employers can now select medical, dental, life, and disability coverage with Aetna Small Group by simply checking the desired plans off on the new application. These new forms, which are attached below for your convenience, are available for use now. We are requiring that the new Employer Application and Employee Enrollment/Change Form be used with groups that have effective dates of May 1, 2003 and forward. Any new cases that are submitted with the old forms for a May 1, 2003 effective date and thereafter will be returned to the broker. Should you have any questions, or if you would like additional printed copies of these forms, please contact your Aetna Sales Manager. As always, thank you for your continued support and dedication. New Pennsylvania Small Group Business Employer Application: pa_er_app.pdf New Pennsylvania Small Group Business Employee Enrollment/Change Form: pa_ee_app.pdf “Aetna” is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and Aetna Health Inc. Pennsylvania Small Group Business Employer Application FOR GROUP COVERAGE (2 – 50 ELIGIBLE EMPLOYEES) Life, Accidental Death & Dismemberment, Disability and Aetna Choice Plan PPO are underwritten by Aetna Life Insurance Company. Aetna Primary Care Plan HMO and Aetna Choice Plan POS are underwritten by Aetna Health Inc. Dental plans are provided or administered by Aetna Health Inc. and Aetna Life Insurance Company. Company Name (Legal Name) DBA/Doing Business As (if applicable) Street Address (P.O. Box not acceptable) City State Zip Billing Address (If different than above) City State Zip Company Contact Person — Title Phone Number ( ) Fax Number ( ) E-Mail Address Federal Tax ID Number Date Business Established (Mo/Yr): Employer Classification ❏ Corporation ❏ Non-Profit ❏ Partnership Medical Coverage Selection ❏ Sole Proprietor ❏ Other: SIC Code: Dental Coverage Selection (Limited to one selection) Aetna Primary Care™ Plan HMO ❏ Value ❏ Standard Groups with 10 – 50 eligible employees who have selected an Aetna HMO or POS medical plan can select any Dental plan. Groups with 26 – 50 eligible employees who have not selected an Aetna medical plan can select either the Standard or Premier Dental plan. ❏ Premier Aetna Primary Care™ Plan HMO — No Referrals ❏ Value ❏ Standard ❏ Premier Aetna Choice™ Plan POS ❏ Value ❏ Standard ❏ Premier Aetna Choice Plan POS — No Referrals ❏ Value ❏ Standard ❏ Premier Aetna Dental™ Plans ❏ Value HMO Rider ❏ Standard: ❏ Freedom of Choice or ❏ Dual Choice ❏ Premier: ❏ Freedom of Choice or ❏ Dual Choice ™ Aetna Primary Care Plan HMO — Deductible and Coinsurance ❏ Value ❏ Standard ❏ Premier ™ Aetna Out-of-Area Plan PPO (Limited to Out-of-Area Employees) ❏ Out-of-Area Plan Life, Accidental Death & Dismemberment, & Disability Coverage Selections Groups with 10 to 50 eligible employees may select one, two or three options for Life, Accidental Death & Dismemberment and Disability. If more than one option is selected, describe each class of employees, indicate the amount selected for each class and attach a list of employee names with each class designation. (Limited to 3 classes. The highest option selected can be no more than 5 times the lowest option.) Class 1 All Groups Life ❏ ❏ ❏ ❏ $10,000 $15,000 $20,000 $50,000 Additional ❏ $75,000 options for ❏ $100,000 Groups with ❏ $125,000 10 – 50 eligible employees or Life & Disability Packaged Plan ❏ Low ❏ Medium ❏ High Class 2 Life ❏ ❏ ❏ ❏ $10,000 $15,000 $20,000 $50,000 or Life & Disability Packaged Plan ❏ Low ❏ Medium ❏ High ❏ $75,000 ❏ $100,000 ❏ $125,000 Class 3 Life & Disability or Packaged Plan Life ❏ ❏ ❏ ❏ $10,000 $15,000 $20,000 $50,000 ❏ $75,000 ❏ $100,000 ❏ $125,000 Class Description Optional Dependent Term Life (Available only to groups with 10 to 50 eligible employees.) GR-96241-PA (1/03) ❏ Yes ❏ No ❏ Low ❏ Medium ❏ High Effective Date Actual effective date will be assigned by the Aetna underwriting department if application is approved. Requested effective date (may be the 1st or 15th of the month only): _______________________________________________________ Employer Contribution(s) Medical Dental Basic Employee Term Life (including AD&D) Optional Dependent Term Life Disability Employer’s Contribution for Employee Coverage Employer’s Contribution for Dependent Coverage % Contribution __________% __________% __________% % Contribution __________% __________% __________% __________% Groups with 2 to 50 eligible employees: The employer must contribute at least 50% of the employee-only annual premium. Coverage can be denied based on inadequate contributions. Section 125 Plan Does the group have a flex plan under Section 125 of the Internal Revenue Service code? ❏ Yes ❏ No Employee Eligibility Work Location (list by state) Full-time (based on number of minimum hours allowed by state law) Part-time Number of Employees Retired COBRA or State Continuees Other (i.e., temporary, substitute, seasonal) Total number of employees: _____________ Total number of employees eligible for coverage (must work a minimum of 30 hours per week): ___________________________________ Total number of employees waiving Aetna health benefits but covered through their spouse’s health benefit plan: ____________________ Total number of employees waiving Aetna health benefits coverage without coverage elsewhere: ___________________________________ Total number of employees covered under another health benefit plan offered by the employer: ___________________________________ Are there excluded classes of employees other than part-time and temporary employees (for example, Union employees)? ❏ Yes ❏ No If Yes, describe excluded class(es): _______________________________________________________________________ Eligibility date will be the first day of the policy month following the waiting period. Waiting period for future employees: ❏ 0 days ❏ 30 days ❏ 60 days ❏ 90 days ❏ 120 days ❏ 180 days Workers’ Compensation Information Aetna’s coverage is not occupational in nature and, consequently, it is not a substitute for Workers’ Compensation coverage. Name of current Workers’ Compensation carrier: ___________________________________________________ Renewal Date: _____________ Is Workers’ Compensation coverage provided on all employees? ❏ Yes ❏ No If not, please provide a list of all employees enrolling that are NOT covered by Workers’ Compensation or similar legislation (including title). Medical Information Is any person to be covered unable to work due to illness or injury? ❏ Yes ❏ No Is any person unable to perform the normal duties of another person in the same employment class of the same age and sex? ❏ Yes ❏ No If yes is answered to either question, attach a sheet with the names of the individual(s), dates and degree of recovery. Prior Carrier Information Health: Will coverage be transferring from another carrier: ❏ Yes ❏ No If yes, name of the carrier: ________________________________________________ Proposed Termination If prior carrier is Aetna, provide group or control #: _________________________ Total Replacement: Has the group been uninsured for three or more months prior to the requested effective date: Dental: Will coverage be transferring from another carrier: ❏ Yes ❏ No If yes, name of the carrier: ________________________________________________ Proposed Termination If prior carrier is Aetna, provide group or control #: _________________________ Total Replacement: Prior Coverage included coverage for (check all that apply) ❏ Major Services ❏ Orthodontia Has the group been uninsured for three or more months prior to the requested effective date: Life and AD&D: Will coverage be transferring from another carrier: ❏ Yes ❏ No If yes, name of the carrier: ________________________________________________ Proposed Termination If prior carrier is Aetna, provide group or control #: _________________________ Total Replacement: Disability: Will coverage be transferring from another carrier: ❏ Yes ❏ No If yes, name of the carrier: ________________________________________________ Proposed Termination If prior carrier is Aetna, provide group or control #: _________________________ Total Replacement: Date: ________________________ ❏ Yes ❏ No ❏ Yes ❏ No Date: ________________________ ❏ Yes ❏ No ❏ Yes ❏ No Date: ________________________ ❏ Yes ❏ No Date: ________________________ ❏ Yes ❏ No Signature Section The Applicant agrees that at no time shall any employee be permitted or required to contribute for non-contributory coverage; or, unless the change is approved in writing by an authorized representative of Aetna, to make contributions for contributory coverage at a rate higher than the initial contribution rate applicable for the employee’s then current coverage. It is agreed that no coverage shall become effective as to any person who is not then a bona fide, full-time employee, regularly performing the duties of his or her occupation, unless otherwise specifically provided in the plan documents (which consist of the Group Policy and/or Group Agreement). All statements herein shall be deemed representations and not warranties. The Applicant acknowledges that it has selected this plan based upon written information provided by Aetna and that no broker, agent or consultant is authorized to modify the terms of the offer or to agree to changes. All material terms of plan coverage are set forth in the plan documents. Applicant agrees to make payroll and other records directly related to employee’s coverage under the Group Agreement or Group Policy available to Aetna for inspection, at Aetna’s expense, at Applicant’s office, during regular business hours, upon reasonable advance request. This provision shall survive termination of the Group Agreement or Group Policy. Applicant has selected, in accordance with applicable state law, the plan to be offered to Applicant’s employees and Applicant has solely determined any/all health plan options for the Applicant’s employees and the contribution amounts. In accordance with current IRS regulations and the 1986 Tax Reform Act, a life insurance schedule may be deemed discriminatory and result in imputed income tax to certain employees and possibly an excise tax to employers. Employers should consult with legal counsel prior to electing a schedule. Aetna disclaims any responsibility if the employer elects such a schedule and it is later deemed discriminatory. The plan documents will determine the contractual provisions, including procedures, exclusions and limitations relating to the plan and will govern in the event they conflict with any benefits comparison, summary or other description of the plan. Participating physicians, hospitals and other health care providers are independent contractors and are neither agents nor employees of Aetna. Applicant agrees to deliver, or otherwise make available to enrollees, all Aetna paper or online member documents and other plan-related materials upon request by Aetna. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing 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. All data that may have a bearing on coverage or premiums will be open for Aetna to inspect while the Group Agreement or Group Policy is in force. The availability of a plan or program may vary by geographic service area. Some benefits are subject to limitations or maximums. Aetna does not provide health or dental care services and, therefore, cannot guarantee any results or outcome. I hereby apply for the coverage(s) indicated above. I certify that all information provided in this application is accurate and complete to the best of my knowledge and belief. I understand that this application will form a part of the Group Agreement or Group Policy issued by Aetna (a sample of which may be available on request), and by my signature below I agree to be bound by the terms and conditions of that Group Agreement or Group Policy. I understand that Aetna may choose not to accept this application at its sole discretion. Signed at (Location): _____________________________________ City, State _____________________________________ Applicant (Company Name) By: _____________________________________ Authorized Applicant Signature _____________________________________ Official Title _____________________________________ Witness _____________________________________ Date Agent/Broker Certification I hereby certify that I am not aware of any information not disclosed in this application by the client which may have bearing on this risk, including my knowledge that replacement life insurance is ❏ is not ❏ (check one) a part of this transaction. I hereby certify that I am licensed and appointed to sell Aetna Small Goup products in the state of Pennsylvania. I hereby certify that I have advised the client not to terminate any existing coverage until receiving written notice from Aetna that the coverage being applied for by this application is accepted. Agent/Broker Name:___________________________________________ Aetna Agent Number/Tax ID/SSN: _____________________________ Agency Name: ________________________________________________ % of Credit:_________________________________________________ Phone Number: (___ _)___________________________________________ Fax Number: (____ )____________________________________________ Address: _________________________________________ Signature ________________________________ City: _______________________________ State: ______ Zip:_______________ Date_____________ E-Mail Address: ______________________________________________ Agent/Broker Name:___________________________________________ Aetna Agent Number/Tax ID/SSN: _____________________________ Agency Name: ________________________________________________ % of Credit:_________________________________________________ Phone Number: (___ _)___________________________________________ Fax Number: (____ )____________________________________________ Address: _________________________________________ Signature ________________________________ City: _______________________________ State: ______ Zip:_______________ Date_____________ E-Mail Address: ______________________________________________ General Agent Name: _________________________________________ Aetna Agent Number/ID Number: ____________________________ Phone Number: (___ _)____________________________________________ Fax Number: (____ )_____________________________________________ Address: _________________________________________ Signature ________________________________ City: _______________________________ Date_____________ State: ______ Zip:_______________ E-Mail Address: ______________________________________________ Administration Kits Send Administration Kits to: ❏ Group ❏ Agent/Broker ❏ General Agent For Aetna Use Only Group Number _______________________ Control Number _________________________ SCD _________________________________ Effective Date _________________________ MRU ___________________________________ Prospect ID___________________________ ©2003 Aetna Inc. GR-96241-PA (1/03) Embedded Secure Document The file http://www.aetna.com/producer/data/sbc/pa_ee_app.pdf is a secure document that has been embedded in this document. Double click the pushpin to view pa_ee_app.pdf. http://www.aetna.com/producer/data/sbc/pa_ee_app.pdf [03/19/2003 2:20:50 PM]