Fill and Sign the Src Proposal Form 2000 San Francisco Bay Area Science Fair Sfbasf

North Carolina Small Group Business Joinder Agreement and Employer Application FOR GROUP COVERAGE (GROUPS OF FEWER THAN 51 ELIGIBLE EMPLOYEES) Life, Accidental Death & Dismemberment, Disability, Aetna Managed Choice® (Open Access), Aetna PPO plans, and Aetna Indemnity plans are underwritten by Aetna Life Insurance Company. Aetna Choice® POS (Open Access) and Aetna HMO (Open Access) plans are underwritten by Aetna Health Inc. Company Name (Legal Name) DBA/Doing Business As (if applicable) Street Address (P.O. Box not acceptable) City State ZIP Bill Address (if different than above) City State ZIP Company Contact Person - Title Phone Number ( ) Federal Tax ID Number Fax Number ( ) Date Business Established (Mo/Yr): E-Mail Address Employer Classification: Corporation Non-Profit SIC Code or Industry Type: Partnership Sole Proprietor LLC Nature of Business: LLP Other: Effective Date Requested effective date (May be the 1st or 15th of the month only. The actual effective date will be assigned by the Aetna underwriting department if application is approved.) Medical Coverage Selection Dental Coverage Selection Aetna Choice® POS (Open Access) – Plan Option Aetna HMO (Open Access) – Plan Option Aetna Managed Choice® (Open Access) – Plan Option Does this group qualify for the small employer exemption under Federal Mental Health Parity? Yes No Is employer, plan sponsor, or a third party funding any of the deductible? Yes No If “Yes,” how much? Aetna DentalTM Plan Standard Plans: Option 1: Schedule Option 2: PPO 1000 Option 3: PPO 1500 Option 4: DentalFund/PPO Max Out-of-State PPO Max: 1000 Voluntary Plans: Option V1: PPO 1000 Out-of-State PPO Max: 1000 1500 Orthodontic coverage is available only to groups with 10 or more eligible employees and for Dependent Children Only in Standard Plan Options 2 and 3 and Voluntary Plan Option V1. Does this group have a flex plan under Section 125 of the Internal Revenue Service Code? Yes No Life, Short Term Disability and Packaged Life and Disability Coverage Selections Groups with 10 to 50 employees may select one, two or three options for Life, Short Term Disability and Packaged Life 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.) All groups: 10,000 5,000 20,000 Groups with 10-50 Eligibles: 75,000 100,000 125,000 Life Disability Packaged Plan: Low Low 2 Medium Medium 2 Option 2 100 200 Short Term Disability: Class Description: Option 1 Class 1 50,000 Class 2 Optional Dependent Term Life (10 to 50 eligible employees only): Yes High 300 400 Class 3 500 No 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-NC (10-10) 1 R-POD E Employer/Employee Contribution(s) Medical Voluntary Dental Dental Employee Life Dependent Life Employer Contribution for Employee Disability Packaged Life & Disability NA NA NA Employer Contribution for Dependent NA % Employee Disability Contribution Percentage NA NA NA NA NA Check one: NA Pre-Tax Post-Tax Business Eligibility Is your company a subsidiary of another company, an affiliate of another company, or under common control with another company? Does your company file state or federal taxes with another company(ies) on a combined or consolidated basis? If Yes to any questions, complete the information below. - A copy of the Quarterly Wage and Tax Statement must be provided for each group to be included for coverage. - If you file or are eligible to file multiple businesses under one tax ID number, all businesses must be included as one group. Business Name Tax Identification Number Percentage of Ownership Owner’s Name Number of Employees Yes No Yes No Is group to be included? Yes No Yes No Yes No Yes No If you have answered “No” to “Is the group to be included” above, please explain why. Is your company a branch of another company, or does your company have branch offices? If Yes - Is each branch office a separate legal entity? - Is each branch a location of one legal entity? - How many branch offices are there? - Are taxes filed separately or as one common filing? - Where is each branch located? (List each branch business address separately.) Yes Yes Yes No No No Yes No Number of Employees at each location Has your business been insured with Aetna within the past 24 months? If Yes, provide group number. Do you use the services of a Payroll Company? If Yes, provide the name of the payroll company. Are you currently a client company of a Professional Employer Organization (PEO)? If Yes - Is group coverage available to you as a client of a PEO? - Is the group considered a Co-Employer with the PEO? - By enrolling for coverage as a small employer I am not in violation of any contractual breach of contract with the PEO. Yes No Yes No Yes Yes No No Yes Agree Disagree No Employer Eligibility/Employee Status Number of Employees Work Location (list by state) Total number of eligible employees Full-time Total number of employees enrolling Part-time Retired COBRA 1099 Union Other (Temporary, substitute, seasonal, etc.) Total number of employees waiving Total number of employees in benefit waiting period Are there excluded classes of employees other than part-time and temporary employees (for example, Union employees)? If Yes, describe class(es) and/or the union local name and number. Yes No Do you have any employees currently in the Armed Forces? Yes No Is your group Medicare Primary (employed less than 20 employees during at least 50% of the preceding calendar year) or Aetna Primary (employed 20 or more employees during at least 50% of the preceding calendar year? GR-96241-NC (10-10) 2 Medicare Primary Aetna Primary Benefit Waiting Period The eligibility date will be the first day of the policy month following the waiting period except when 90 days exact is requested. Waive the waiting period for present employees enrolling with the group (even those who have not met the full waiting Yes period). Waiting period for future employees: 0 Days 30 Days 60 Days 90 Days exact No Employees must be added to the group coverage no later than 90 days after their first day of employment. Prior Carrier Information Health Is this group transferring from another group carrier? If Yes, provide Carrier Name and Telephone Number Effective Date of Coverage Dental Life Disability Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes Individual $ Family $ No Proposed Termination Date Is this total replacement? If prior carrier is Aetna, provide Group/Control Number Did your plan have a deductible? Prior Carrier Deductibles: Yes No Individual $ Family $ Ortho Maximum $ Major Services Orthodontia Dental Only Prior Dental coverage, check all that apply: Medical Information Is any person to be covered unable to work due to illness or injury? Is any person unable to perform the normal duties of another person in the same employment class of the same age and sex? If Yes is answered to either question, attach a sheet with the names of the individual(s), dates and degree of recovery. Yes No 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 position 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 position schedule. Aetna disclaims any responsibility if the employer elects such a position schedule and it is later deemed discriminatory. Information on agent’s compensation is available from your agent or at Aetna.com. 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. 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. 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 will rely on the information I provide in determining eligibility for coverage, setting premium rates, compliance with applicable laws, and other purposes, and that any material misrepresentation or fraudulent statement may result in rescission of the group policy, termination of coverage, increase in premiums, or other consequences. Aetna reserves the right to audit and to request documentation as evidence of business activity at any time and from time to time in order to validate my compliance with eligibility and underwriting guidelines as well as validate the applicability of State and Federal laws. I understand that my failure to comply with any such request may also result in termination of coverage, increase in premiums, or other consequences. continued GR-96241-NC (10-10) 3 Signature Section (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. Any person who knowingly and with intent to injure, defraud or deceive 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 may be a crime and subjects such person to criminal and civil penalties. Signed at (Location): City, State Applicant (Company Name) Authorized Applicant Signature Official Title Print Name of Authorized Applicant Date By: NOTE: As defined in North Carolina law, a “religious employer” can exclude coverage for prescription contraceptive drugs or devices. This is Exclude in accordance with North Carolina law § 58-3-178. Please check here to exclude contraceptive coverage. 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, is not (check one) a part of this transaction. including my knowledge that replacement life insurance is 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. Broker Name: SSN Agency Name : TIN: Pay commissions to: (check one) Broker Agency Address: Signature: Date: Phone: Fax: City: State: Email Address: Broker Name: SSN Agency Name : TIN: Pay commissions to: (check one) Broker Agency Address: Signature: Date: Fax: City: State: Email Address: TIN: Phone: Fax: Address: City: Signature: % of credit: Phone: General Agent Name: Date: State: Email Address: SCD Effective Date Appointment Expiration Date: No Corporate Headquarters Aetna Health Inc. 1302 Concourse Drive Suite 402 Linthicum, MD 21090 GR-96241-NC (10-10) Aetna Life Insurance Company 151 Farmington Avenue Hartford, CT 06156 4 ZIP: % of credit: For Aetna Use Only Group Number Control Number Is Agent/Agency licensed and appointed? Yes ZIP: ZIP: % of credit: