Fill and Sign the Subcontractor Prequalification Form Schmid Construction

[AETNA US HEALTHCARE] EMPLOYER APPLICATION FORM 1. GROUP INFORMATION GROUP NUMBER: (For Internal Use Only) Company Name: NO. ELIGIBLE: Parent Co. Name: Contract Address: NO. ENROLLED: IMO City: State: Zip Code: Federal Tax ID No. No CSA Number Required (See Section 2) SIC Code: Contact Name: Yes Title: Will customer submit Telephone: E-mail Address: enrollments electronically? Yes No E-mail Contact Name: Prior NYLCare Customer?: x No Yes If Yes, list NYLC Group Number: Prior CHI Customer?: x No Yes If Yes, list CHI Group Number: Prior CHA Customer?: x No Yes If Yes, list CHA Group Number: Prior Prudential Customer?: x No Yes Will EZLink be used: Yes No If Yes, list Pru. Group Number: Group Category: National Acct. Prudential Acct. Structure: Duplicate PHC Structure If current [AUSHC] Customer, Identify [AUSHC] Group Number: New Structure Middle Market Standard Risk (Small) Site Address: City: Eligible / Enrolled: State: / Zip: Site Address: City: Eligible / Enrolled: State: Zip: / Site Address: City: Eligible / Enrolled: State: / Zip: Site Address: City: Eligible / Enrolled: State: Zip: / 2. BENEFIT INFORMATION Enter Service Areas to be included, by Region: Mid-Atlantic: DE, NJ, PA PLEASE ATTACH SIGN RATE QUOTATION(S) FOR EACH PLAN AND SERVICE AREA. Service Area: Quote ID: Control No. Suffix NY, CT, MA, NH, VT, ME Southeast: FL, Wash DC, VA, NC, SC, GA, AL, MD, PR, AR, MS Account: (3 digits) (7 digits) Northeast: (5 digits) Benefit Description: Service Area: Quote ID: Control No. Suffix Account: (3 digits) (7 digits) (5 digits) Benefit Description: Mid-West: IL, TN, KY, IN, OH, WI, MI, WV Service Area: Quote ID: Control No. Suffix (7 digits) West Central: TX, LA, MT, WY, CO, NM, ND, SD, NE, KS, OK, MN, IA, MO West: CA, AZ, WA, OR, NV, ID, UT, AK, HI Account: (3 digits) (5 digits) Benefit Description: Service Area: Quote ID: Control No. Suffix (7 digits) Account: (3 digits) (5 digits) Benefit Description: 3. BENEFIT EXCLUSIONS / COMMENTS NB903 Employer App-Generic-State Specific 1 rev: 5-15-01 EMPLOYER APPLICATION FORM (Cont'd) Company Name: Group Number: 4. ELIGIBILITY x Standard: dependents up to age 19, students to age 23; covered to next premium due date. Other (must attach special rates from group analysis if greater than 25). Handicap Provision (must attach group analysis memo). Covered to: Dependents to Age Next premium due date Students to Age Calendar year* Handicap Prior to Age Next renewal* *Group analysis approval required. Custom ID Cards requested: No Yes If Plan Sponsor elects to verify student status or requires Custom ID cards, refer to the following website for additional paperwork requirements. New Hires: New hire waiting period: New Hire Effective Date: Termination of Coverage: a. 1st of the month following the waiting period. a. End of the month b. 15th of the month following the waiting period. b. Date of termination c. Immediately following the waiting period. Must Select Protection Stops: d. Must Select Protection Starts: A B Date of hire. Customer must have a new hire wait period of 000 (zero) days. Must Select Protection Starts: A B A B NOTE: Protection Starts and Stops must be consistent Protection Starts A: If premium due date is the 1st of the month and if membership is effective between the 1st and the 15th of the month, inclusive, the premium for the whole month will be paid. If membership is effective between the 16th and the 31st of the month, inclusive, no premium will be paid for the first month of membership. If premium due date is the 15th of the month and if membership is effective between the 15th and the 31st of the month, inclusive, the premium for the whole month will be paid. If membership is effective between the 1st and the 14th, inclusive, no premium will be paid for the first month of membership. Protection Starts B: For all newly eligible employees whose coverage does not begin on the premium due date, one-half the monthly premium will be paid. For all newly eligible members whose coverage begins on a premium due date, a full month's premium will be paid. 5. GROUP TYPE (check all that apply) National Account (50): Manager Small Group (10) [AUSHC] Def. Key Account (51): Rep Coder Small Group (11) State Reform Def. National Key Account (52): Small Broker Group (25) [AUSHC] Def. x Broker Account (20/25): Broker Manager Broker Name Small Broker Group (26) State Reform Def. Phone: NY City Municipality (32) Agency Name NY City Mun. Key Acct. (53) Address Non-NY City Municipality (33) City State: ZIP: Non-NY City Mun. Key Acct. (54) General Agent (if applicable) Managed Care Coordinators (70) Agent Name Phone: House Account (55) [AUSHC] Def. Agency Name House Account (56) State Reform Def. Address City Federal/Public Sector (30) State: ZIP: State Government (35) Medicaid (60) COBRA (42) Corporate (01) Medicare (40) (quote must be attached and subgroup 50 set up) Other NB903 Employer App-Generic-State Specific 2 rev: 5-15-01 EMPLOYER APPLICATION FORM (Cont'd) Company Name: Group Number: 6. EMPLOYEE ELIGIBILITY ELIGIBLE CLASS OF EMPLOYEES: CONTRIBUTION POLICY: Active full-time working a minimum of 25 hrs./wk.* Employees will not contribute *State mandated minimum hours may be different Other (questionnaire required and group analysis approval) Employees will contribute % Single % Family Does group have a flex plan under Section 125 of the Internal Revenue Code? Yes No Has the group been uninsured 3 months or more prior to issue? Yes No 7. BILLING INFORMATION BILLING ADDRESS: Name Address City State Zip Code: Yes (Complete Consolidation Request Form) Consolidate: x No Self Bill: x No One Invoice: Yes No Multiple Invoices: Yes* Yes No *Will Customer Receive Invoice (Y/N): COBRA Billing: (If Applicable) ROSTER SEQUENCE: Order of importance (1-5) 1=Highest priority Member ID No. Alpha (last name) Group Plan Bill: Group Soc. Sec. Number Home Group No. TPA* Set up subgroup for COBRA enrollees: Yes (attach signed quotation) 1 Grps. Location No. No Name Address City State Zip *TPA - Requires an additional COBRA subgroup to be set up. 8. CONTRACT INFORMATION Effective Date Tier Structure Renewal Month Tier Structure (enter 2, 3, or 4): 4 IMPORTANT INFORMATION Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files and 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. For Florida group applicants, any person who knowingly and with intent to injure, defraud, or deceive any insurer, files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. For Maine group applicants, it is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. For Pennsylvania group applicants, 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. NB903 Employer App-Generic-State Specific 3 rev: 5-15-01 EMPLOYER APPLICATION FORM (Cont'd) Company Name: Group Number: CONDITIONS OF ENROLLMENT - Applicant Acknowledgments and Agreements I agree to or with the following: 1. Group acknowledges that it has selected this [Aetna U.S. Healthcare] plan based upon information provided by [Aetna U.S. Healthcare] and the group's brokers, agents, employees or consultants. All material terms of the plan coverage are contained in the plan documents*. 2. Group has selected the [Aetna U.S. Healthcare] plan to be offered to group's employees and group has solely determined any/all health plan options for the group's employees and the contributing amounts. 3. The plan documents* will determine the rights and responsibilities of member(s) and will govern in the event they conflict with any benefits comparison, summary or other description of the plan. 4. Group acknowledges that [Aetna U.S. Healthcare's] participating providers, including all participating primary care physicians, are independent contractors and are neither agents nor employees of [Aetna U.S. Healthcare]. * Group Insurance Certificate, Group Policy, Group Agreement, Schedule of Benefits, Certificate of Coverage. 9. EMPLOYER AUTHORIZATION It is understood and agreed that this application is part of the enrollment process and this application is subject to [Aetna US Healthcare] corporate approval. I have signed rate quotations for the agreed upon plan offerings. Employer Signature Title Date 10. MARKETING REPRESENTATIVE APPROVAL I verify that the above information is accurate and complete to the best of my knowledge. Sole Carrier Yes If NO, other carrier(s) No Marketing Representative Signature Print Name and Phone No: If YES, total: Sales Office: HMO Products Date HMO Products Indemnity New Business Rep. Code Self-Insured under the traditional plan Est. Rep. Code Yes x No Forward all completed paperwork to the appropriate HMO Employer Services Region(s) for processing. Refer to [NB902 HMO Regional Info Form] NOTE: Group Analysis approval is necessary for any changes which deviate from the standard contract. NB903 Employer App-Generic-State Specific 4 rev: 5-15-01