NEW JERSEY APPLICATION FOR A SMALL EMPLOYER
FOR GROUP COVERAGE (2 – 50 ELIGIBLE EMPLOYEES)
LIFE, DISABILITY AND DENTAL BENEFITS POLICY
Please Print or Type
New Policy
For Aetna Use Only
Change in Policy
Control Number
Requested Effective Date
NOTE: The Effective Date will be on or after the date Aetna approves the application.
Section I: POLICYHOLDER INFORMATION
1. Policyholder (Full Legal Name of Company)
2. Tax Identification Number
3. Main Address
City
State
Zip
Mailing Address
City
State
Zip
Telephone Number
Facsimile Number
(
(
)
4. Name of Contact
)
Title
Telephone
5. Type of Organization
Corporation
Partnership
Proprietorship
Other (explain):
6. Nature of Business (specify)
SIC Code
7. Number of eligible employees in your company
Refer to Section III for the definition of an eligible employee.
8. Number eligible employees to be insured
9. Class or classes to be excluded
10. Insurance requested for
Employees Only
Employees and Dependents
Should the plan provide dental coverage for domestic partners as permitted by P.L. 2003, c.246?
Yes
No
If "Yes", should the plan provide dental coverage for coverage of children of covered domestic partners?
Yes
No
If applying for Aetna medical benefits along with this application or if you currently have Aetna medical benefits and are adding
Dental, this election must be consistent with your Aetna medical benefits selection.
11. Is the Employer subject to the requirements of COBRA?
Yes
No
12. Waiting period before employees become insured (may not exceed 6 months):
Present Employees:
New or Rehired Employees:
If applying for Aetna medical benefits along with this application or if you currently have Aetna medical benefits and are adding
Dental, this election must be consistent with your Aetna medical benefits selection.
13. What percentage of the premium will the employer pay?
Life
%
Disability
%
Dental
%
(Life/Disability requirement: Employer must contribute 100% of the total cost of the basic Life plan for groups with 2 – 9 eligible
employees; employers must contribute at least 50% of the total cost of the plans for groups with 10 – 50 eligible employees.
Dental Requirement: Employer must contribute at least 50% of the cost of Employee Only coverage for Dental Plan.)
14. Deposit
$
Premium Paid: Monthly
Premium will be due as of the effective date.
The premium for the first month of coverage must be attached.
Affiliates, subsidiaries or branches (Must be included for the purposes of participation)
Legal Name and Location
GR-96241-NJ LIFE (4-05)
No. Eligible Employees
In This Company
No. Eligible Employees
To Be Insured
R-POD
Section II: SPECIFICATIONS FOR COVERAGE
LIFE AND DISABILITY PLAN OPTIONS:
Groups with 10 to 50 eligible employees may select one, two or three options for Life, Accidental Death & Dismemberment and Disability, with a
minimum requirement of three employees in each option. 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
Class 2
Class 3
Life & Disability
Life & Disability
Life & Disability
All Groups
Life*
or Packaged Plan Life*
or Packaged Plan Life*
or Packaged Plan
$10,000
Low
$10,000
Low
$10,000
Low
$15,000
Medium
$15,000
Medium
$15,000
Medium
$20,000
High
$20,000
High
$20,000
High
Plans include
Plans include
Plans include
$50,000
$50,000
$50,000
Dependent Term
Dependent Term
Dependent Term
Life
Life
Life
$75,000
$75,000
$75,000
Additional
$100,000
$100,000
$100,000
options for
Groups with
$125,000
$125,000
$125,000
10 – 50 eligible
employees
Class
Description
*Optional Dependent Term Life (Available only to groups with 10 to 50 eligible employees.)
DENTAL COVERAGE SELECTION
Contributory Plans:
Option 2: DMO
Option 3: Freedom-of-Choice
Option 4: PPO Max
Option 5: Active PPO-High Option
Option 6: PPO 1500
Option 7: Consumer Directed DentalFund
Voluntary Plans:
Option V2: DMO
Option V3: Freedom-of-Choice
Option V4: PPO Max
Option V7: Consumer Directed
Yes
No
Contributory Out-of-State PPO Plan
(if applicable)
Low Option
Medium Option
Voluntary Out-of-State PPO Plan
(if applicable)
Low Option
Orthodontic coverage for dependent children is included in Plan Options 2, 3, 5, 6, V2, and V3 and available only to groups
with 10 or more eligible employees.
For groups with less than 25 employees, DMO (option 2) can be sold standalone or packaged with PPO options 4-6. For groups with 25 or
more employees, DMO (option 2) must be packaged with one of the PPO options 4-6 or offered as part of the Freedom-of-Choice plan
(option 3). The Consumer Directed DentalFund (option 7) cannot be sold with any other dental option. For groups with 3 or more
employees, Voluntary Option V2-DMO must be offered with Voluntary Option V4-PPO Max.
Section III: ALL QUESTIONS MUST BE ANSWERED
Please indicate below the number of employees by work location/state. All employees must be included, regardless of whether or not they
currently have medical coverage and through whom that coverage is provided.
Number of Employees
Work Location
(list by state)
Full-time
Part-time
Retired
COBRA or
State Continuees
Other
An Eligible Employee is one who works on a full-time basis with a normal work week of 25 or more hours for compensation. An employee who
works less than 25 hours per week or works on a temporary or substitute basis, or participates in an employee welfare arrangement established
pursuant to a collective bargaining agreement is not an eligible employee.
Total number of eligible employees:
Total number of eligible employees applying/enrolling for Life
/Disability
/Dental
benefit coverage.
Total number of eligible employees waiving Life/Disability/Dental benefit coverage under the policy with coverage
under their spouse's coverage or any other Life/Disability/Dental Benefits Plan offered by the employer:
Life
/Disability
/Dental
GR-96241-NJ LIFE (4-05)
Section III: ALL QUESTIONS MUST BE ANSWERED (Continued)
Total number of eligible employees waiving Life/Disability/Dental benefit coverage under the policy without coverage
under a spouse's coverage or any other Life/Disability/Dental Benefits Plan offered by the employer:
Life
/Disability
/Dental
Total number of employees in an ineligible class or classes:
Section IV: PRIOR CARRIER INFORMATION
Dental:
Will coverage be transferring from another carrier:
Yes
No
Proposed Termination Date:
If Yes, name of the carrier:
If prior carrier is Aetna, provide group or control #:
Proposed Termination Date:
Major Services
Orthodontia
Prior coverage included coverage for (check all that apply)
Has the group been uninsured for three or more months prior to the requested effective date:
Yes
No
Life:
Will coverage be transferring from another carrier:
Yes
No
Proposed Termination Date:
If Yes, name of the carrier:
Proposed Termination Date:
If prior carrier is Aetna, provide group or control #:
Disability:
Will coverage be transferring from another carrier:
Yes
No
Proposed Termination Date:
If Yes, name of the carrier:
Proposed Termination Date:
If prior carrier is Aetna, provide group or control #:
Section V: AGENT/PRODUCER INFORMATION
Agent/Broker Name:
Agency Name:
Phone Number: (
Address:
Signature:
Agent/Broker Name:
Agency Name:
Phone Number: (
Address:
Signature:
General Agent Name:
Phone Number: (
Address:
Signature:
Date:
Aetna Agent Number/Tax ID/SSN:
% of Credit:
Fax Number: (
)
State:
E-Mail Address:
Date:
Aetna Agent Number/Tax ID/SSN:
% of Credit:
Fax Number: (
)
State:
E-Mail Address:
Date:
Aetna Agent Number/ID Number:
Fax Number: (
)
State:
E-Mail Address:
)
City:
)
City:
)
City:
Zip:
Zip:
Zip:
Section VI: SIGNATURE
It is understood that except as provided under applicable regulations no individual shall become insured while not actively at work on a full
time basis, and only full-time employees are eligible. A full-time employee is one who regularly works at least 25 hours per week at his
employer's place of business.
It is further understood that no agent has power on behalf of Aetna Life Insurance Company and/or Aetna Dental Inc. to make or modify any
request or application for insurance or to bind Aetna Life Insurance Company and/or Aetna Dental Inc. by making any promise or
representation or by giving or receiving any information.
It is further understood that no insurance will be effective unless and until the application is accepted in writing by Aetna Life Insurance
Company and/or Aetna Dental Inc. Final rates will be based on enrollment data as of the Policy effective date. No contract of insurance is to
be implied in any way on the basis of the completion and/or submission of this application.
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
New Jersey law requires that plan sponsors with 25 or more employees contributing to dental plan organization (DMO) coverage also offer to
covered persons the option of selecting alternative coverage which permits covered persons to obtain dental services from any licensed
dentist.
State law also requires that Aetna Life Insurance Company and/or Aetna Dental Inc. provide affected plan sponsors with copies of the
applicable statutes/regulations and that those plan sponsors furnish to us written verification of their compliance with the law.
Per your signature below, you certify your organization’s receipt of and compliance with New Jersey Statutes 17:48D-9.1 and 9.2 and New
Jersey Administrative Code 11:10-2.1 through 2.6 requiring selection of alternate coverage.
continued
GR-96241-NJ LIFE (4-05)
Section VI: SIGNATURE (Continued)
JOINDER AGREEMENT - REQUEST FOR PARTICIPATION (For life, disability, accidental death and dismemberment, out-of-state
medical and out-of-state dental employee benefits): The undersigned employer agrees to the establishment of an insurance trust fund
("Fund") for the purposes of implementing a Trust Agreement ("Agreement"), and to the designation of the Chase Manhattan Bank Delaware,
Wilmington, DE, as "Trustee" for the Fund and Agreement. The undersigned, as a Participating Employer in the Industry Trust corresponding
to the standard industry classification ("SIC") code selected above: 1) agrees to be bound by the terms of the Agreement and the policy issued
to the Trustee (including any amendments); 2) requests coverage for its eligible employees under the policy (subject to applicable
underwriting requirements) as of the effective date requested or as of the date of approval of the Employer for participation under the
Agreement, whichever is later, and continue as long as the Employer remains actively in business; and 3) agrees to make the required
contributions to the Fund; in the event of default, it will be liable to the insurer for such unpaid contributions for the coverage period, and
such insurer will terminate coverage. The insurer may also terminate coverage as of the date the group fails to meet minimum underwriting
requirements in effect on that date. In addition, the Participating Employer, in accordance with ERISA Title I Section 503, designates Aetna Life
Insurance Company ("Aetna") as the Named Fiduciary under the Plan, with complete and discretionary authority to review all denied claims
for benefits under the Plan, and to construe disputed/doubtful Plan terms. Aetna shall be deemed to have properly exercised such authority
unless it has abused its discretion by acting arbitrarily and capriciously.
I understand that this application will form a part of the Group Agreement or Group Policy issued by Aetna, 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 subject to any state requirements.
Date at
on
Print Name of Officer, Partner or Proprietor
Signature of Officer, Partner or Proprietor
Witness to Signature
Note: If there are any modifications to the statements and answers given in this application (I.e., crossed out, whited-out, erased information),
the applicant must attest to the modifications by giving a complete signature in the margin near the modification.
Section VII: FOR AETNA USE ONLY
Effective Date
Billing
Coverage Code
Type
Pre-Ex
Continuous
Coverage
Transcode
NEW JERSEY - CODE AND STATUTES
New Jersey Administrative Code
11:10-2.1 Purpose
P.L. 1983, Chapters 142 through 145, require that each employer or other organization subject thereto offer its employees or
members the option of selecting alternate coverage which permits covered persons to obtain dental services from any dentist of
their choice whenever the employer is contributing to a dental plan contract (as described in N.J.A.C. 11:10-2.2(a)). These
statutes also direct the Commissioner to promulgate rules and regulations to effectuate their purposes. This subchapter is being
promulgated to meet this statutory mandate and to implement the notification requirements of the statutes.
11:10-2.2 Scope and application
(a) This subchapter applies to each employer or other organization which:
1. Employs or has 25 or more employees or members during the full preceding calendar year; and,
2. Contributes to a dental plan contract.
(b) Insurers, dental plan organizations, and dental service corporations which are authorized to enter into contracts providing
dental coverage are also subject to this subchapter.
11:10-2.3 Definitions
The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates
otherwise:
"Alternative coverage" means a plan that permits covered persons to obtain dental services from any licensed dentist.
"Dental plan contract" means any contract issued by a health insurer, dental plan organization, or dental service corporation
which restricts covered persons in selecting the providers of dental services to a single provider or a limited number of providers.
"Enrollment period" means a period of time, of not less than one month's duration, prior to the renewal of a dental plan contract
during which employees (Publication page references are not available for this document.) or members are afforded the option
to be covered under the dental plan contract or alternative coverage.
"Other organization" means a group of 25 or more members to which a dental plan contract has been or is to be issued
including, but not limited to, labor unions and associations.
"Renewal" means to begin a new term of the contract or to add an amendment to the contract.
GR-96241-NJ LIFE (4-05)
NEW JERSEY - CODE AND STATUTES (Continued)
New Jersey Administrative Code (Continued)
11:10-2.4 Notification of affected parties
(a) An insurer, dental plan organization and dental service corporation shall provide to each employer or other organization to
which this subchapter applies a copy of N.J.S.A. 17:48D-9.1 and 9.2 (as appropriate) and this subchapter at the time of offering
a dental plan contract as defined in this subchapter.
(b) Every employer and other organization subject to this subchapter, shall offer in writing to its employees or members and
their eligible dependents the option of selecting coverage which permits dental services to be obtained from any licensed dentist
as an alternative to the coverage provided under a dental plan contract. For new dental plan contracts being provided for the
first time, this option shall be offered during the period for enrolling the employees or members in the new plan. For existing
dental plan contracts, this option shall be offered during an enrollment period preceding the renewal date of the contract.
Employers and other organizations which have offered this option to existing employees or members shall also offer this option
to new employees or members at the time they are enrolled in a dental plan contract.
(c) Employers and other organizations to which this subchapter applies, shall post in a conspicuous manner, written notice of the
coverage option and the text of P.L. 1983, Chapters 142- 145, whichever chapter is applicable.
11:10-2.5 General rules
(a) Each health insurer, dental service corporation, or dental plan organization shall, at the time a dental plan contract is offered
or at the time of renewal, obtain written verification from each employer or other organization of compliance with P.L. 1983,
c.142 through 145, and this subchapter.
(b) Each employer or other organization, at the time of offering or renewal of a dental plan contract shall furnish to the health
insurer, dental service corporation, or dental plan organization written verification of compliance with P.L. 1983, c.142 through
145 and this subchapter.
(c) Each employer or other organization at the time of offering or renewal of a dental plan contract shall provide in the written
notice required by N.J.A.C. 11:10-2.4(b) and (c) an outline of the differences in coverages and cost to the employee or members
and their eligible dependents between a dental plan contract and the alternative coverage.
(d) The alternative coverage may be provided through an insurance contract, on a self-funded basis, or by any means which
meets the approval of the Commissioner.
(e) Each employer or other organization shall contribute to the alternative coverage an amount equal to the premium or cost
which it pays or contributes to the dental plan contract. Such contribution shall be adjusted when the premium or cost which it
pays or contributes to the dental plan changes.
11:10-2.6 Separability
If any provision of this subchapter, or its application to any person or circumstances, is held invalid, the remainder of this
subchapter and its application to other persons or circumstances shall not be affected.
New Jersey Statutes
17:48D-9.1 Employer must offer alternative dental coverage
Each employer or other organization which employs or has 25 or more employees or members during the full preceding
calendar year and which contributes to a dental plan organization contract which restricts the covered persons in selecting the
providers of dental services to a single provider or limited number of providers, shall also offer its employees and their eligible
dependents and members and members' eligible dependents at the time a dental benefits plan is offered or renewed the option
of selecting alternative coverage which permits covered persons to obtain dental services from any licensed dentist.
17:48D-9.2 Employer contributions
An employer or other organization shall be required to pay for or contribute towards the provision of alternative coverage an
amount equal to the premium or cost which it pays or contributes to the dental plan organization contract which limits the
number of providers of dental service.
Please keep a copy of this application for your records. If the application is accepted by Aetna it becomes part of the
issued Group Agreement and/or Group Policy.
GR-96241-NJ LIFE (4-05)
