Fill and Sign the Loan Application Assistance Agreement between the Borrower and Northwest Business Development Company Form

2011 Enrollment Approved by ___ Date____ Self-Pay Participant Effective Date_____________ - Office Use Only - See the Summary Plan Description for more information: www.oregon.gov/DAS/PEBB/SPD.shtml 1. I am enrolling as a 2. I am New Participant. Eligibility Date: __________ OLCC Agent Post Doc/J1 Visa Blind Business Enterprise Employee Foster Parent (attach copy of Foster Parent Certificate) PEBB Benefit Number (P#########) 3. Contact Information Last Name Nurse working less than half time First Name MI Agency # Gender F M BHS and the plans in which you enroll will send all benefit-related correspondence to your contact address. Contact Address Check if New Address Residence Zip Code Work Zip Code _ / _ _ / Same address? (if N, see below) Y Y _ _ _ (optional) Home Phone (optional) _ Y Last Name You may not enroll children who will turn 27 in 2011. Relationship Key: SP=Spouse, DP=Domestic Partner, CH=Employee and/or Spouse’s child, DP CH=Domestic Partner’s Child, AFF CH=Child by Affidavit, AFF GCH=Grandchild by Affidavit (must attach the correct Affidavit*) First Name M Birth Date (mm/dd/yyyy) Relationship Gender M F Enroll Drop Med Den N 3 County N 2 Zip Personal E-mail Attach separate sheet if necessary. If your dependent has a different contact address, fill out the next section. 1 State Work E-mail 4. Dependent Information # City Work Phone Date of Birth _ Apt # N You must submit a midyear change form to BHS within 30 days of the date when an individual you provide coverage to is no longer PEBB eligible. Individuals will be removed prospectively from coverage the last day of the month in which BHS receives the midyear change form from you. The exception to prospective removal from coverage is when an ex spouse, ex domestic partner or any child becomes ineligible for coverage because of divorce or dissolution of partnership. In this exception, the ineligible individuals will be removed from coverage the last day of the month in which the divorce or dissolution occurred. Late submission may affect your income taxes. In the case of retroactive terminations, you may be responsible for claims paid for the individual during the period of ineligibility. If you do not report changes of eligibility that occur before open enrollment, you may face civil or criminal charges for fraud, and PEBB may rescind coverage. If you checked N above, provide Contact Information for Dependents List addresses for dependents that are different from yours in section 2. Include the number that corresponds to section 3. # Dependent’s Residence Address City State Zip/Country Code County If you listed a Domestic partner above, indicate the type of Domestic Partnership By PEBB Affidavit* *Affidavit By Registered Certificate (no copy required) If you are adding a child or domestic partner by affidavit, you must submit the enrollment form, affidavit, and any required documentation to BHS payroll or university benefit office within the allowed time, or your enrollment will not occur. 107085-00302 (rev. 1/5/2011) 1 of 2 5. Medical and Dental Plans Blind Business Enterprise Employees may enroll only in Medical coverage. Medical Plan Full-time Part-time Plan Plan (select one) I elect to (select one): Enroll in PEBB Medical coverage only Enroll in both PEBB Medical and Dental coverage Dental Plan (select one) Full-time Plan PEBB Statewide Plan Kaiser Permanente Kaiser Permanente ODS Traditional Providence Choice Part-time Plan ODS Preferred Option Willamette Dental 6. Medicare Coverage The following individuals are covered by Medicare: Not Applicable Me Spouse and Domestic Partner Name: A Dependent Child Name: 7. Participant Signature and Authorization I declare that the individuals listed on the enrollment form and I are eligible for the coverage requested. I understand the benefit elections made on this application are in effect for as long as I continue to meet PEBB's eligibility requirements, or until I elect to change them subject to the provisions of PEBB's plan. I have read the benefit materials and I understand the limitations and qualifications of the PEBB benefits program. I understand that: A person who knowingly makes a false statement in connection with an application for any benefit may be subject to imprisonment and fines Knowingly making a false statement may subject me to termination of enrollment, denial of future enrollment, or civil damages. I also understand that if I fail to report on this enrollment form a change that made an enrolled family member ineligible, PEBB may consider my omission an intentional misrepresentation of a fact material to my enrollment. In that case, PEBB may terminate the family member’s coverage retroactively, pursuant to PEBB rules. This form supersedes all forms and submissions I previously made for PEBB coverage. I hereby declare that the above statements are true to the best of my knowledge and belief, and I understand that they are subject to penalty for false claims. _______________________________________________ Participant Signature Send to: Benefit Help Solutions PO Box 67240 Portland, OR 97268-1240 _______________________ Date Portland (503) 765-3581 Toll-free (800) 556-3137 Toll-free Fax (888) 393-2943 Keep a copy of all benefit documents for your records. 107085-00302 (rev. 1/5/2011) 2 of 2