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Aetna Medicare Advantage Application Small Group Employers Effective Date Requested Effective Date Existing Aetna Customer Yes No If existing Aetna customer, Policy/Group Number Employer Information Company Name DBA/Doing Business Address Street Billing Address City State Street Contact Name City Phone Number State Zip Code Fax Number E-mail Address Employer Classification Zip Code Federal Tax ID Number Corporation Nonprofit Partnership LLC Sole Proprietor Other LLP Medicare Product Selection ® Aetna Golden Medicare HMO Plan : HMO 1.4 HMO 5.4 HMO 2.4 HMO 3.4 HMO 4.4 Aetna Golden Choice™ PPO Plans: PPO 1.4 PPO 5.4 PPO 2.4 PPO 3.4 PPO 4.4 Aetna Medicare OpenSM Private-Fee-for-Service Plans: Open Copay 1.4 Open Copay 2.4 Open Coinsurance 1.4 Open Coinsurance 2.4 Applicant Acknowledgements and Agreements The Applicant agrees that at no time shall any individual submitted by Applicant for enrollment in an Aetna Medicare plan (“Enrollee”) 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 Enrollee’s then current coverage. It is agreed that no coverage shall become effective as to any person who is not then a (1) bona fide, full-time employee regularly performing the duties of his or her occupation (subject to applicable HIPAA requirements for health coverage, (2) a bona fide retiree of Applicant, or (3) an eligible dependent of such retiree or employee, unless otherwise specifically agreed to by Aetna and provided in the plan documents (which consist of the Group Agreement and Evidence of Coverage). All statements herein shall be deemed representations and not warranties. CALIFORNIA, OHIO & PENNSYLVANIA CONTRACT SITUS: 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. The Applicant acknowledges that it has selected the coverage specified herein 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 coverage are set forth in the plan documents. Applicant agrees to make payroll and other records directly related to an Enrollee’s coverage under the Group Agreement 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. Applicant has selected, in accordance with applicable law, the coverage to be offered to Applicant's employees and/or retirees and their eligible dependents and Applicant has solely determined any/all coverage options for the Applicant's employees and/or retirees and their eligible dependents and the contribution amounts. The plan documents will determine the contractual provisions, including procedures, exclusions and limitations relating to the coverage and will govern in the event they conflict with any benefits comparison, summary or other description of the coverage With the exception of Aetna Rx Home Delivery, all participating providers and vendors are independent contractors and are neither agents nor employees of Aetna. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed. With respect to those Aetna Medicare plans that are network-based, provider network composition is subject to change. Notice of a change in provider network composition shall be provided to Enrollees in accordance with applicable federal law. Aetna does not provide health or dental care services and, therefore, cannot guarantee any results or outcome. Some benefits are subject to limitations or maximums. Applicant agrees to deliver or otherwise make available to Enrollees all Aetna paper or on-line 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 is in force, and as required under applicable laws, rules and regulations and the Group Agreement. The availability of a plan or program may vary by geographic service area. "Aetna" is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. GR-68448-2 (10-08) CA, OH, PA Important Information 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 is crime and subjects such person to criminal and civil penalties. Any dispute arising from or related to the Group Agreement will be determined by submission to binding arbitration, and not by a lawsuit or resort to court process except as applicable law, as defined in the "Applicable Law" section of the Group Agreement, provides for judicial review of arbitration proceedings. The agreement to arbitrate includes, but is not limited to, disputes involving alleged professional liability or medical malpractice, that is, whether any items and/or medical services covered by the Group Agreement were unnecessary or were unauthorized or were improperly, negligently or incompetently rendered. This agreement also limits certain remedies and precludes the award of punitive damages. See sections “Binding Arbitration” and “Limitations on Remedies” of the Evidence of Coverage for further information. The undersigned representative of the Applicant understands that the Applicant and any Groups eligible through the Applicant, if different from the Applicant, and any individuals who are submitted by Applicant for enrollment in an Aetna Medicare plan (“Members”) are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of binding arbitration. This means that the Applicant, Groups, Members, and other interested parties will not be able to try their case in court. The undersigned representative of the Applicant further understands and accepts that the Applicant, Groups and Members are giving up certain remedies and that there may be certain limitations to the recovery of punitive damages. Signature Section 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 issued by Aetna and by my signature below, I agree to be bound by the terms and conditions of that Group Agreement. Aetna will issue a new Group Agreement to Applicant on an annual basis. I understand that Aetna may choose not to accept this application at its sole discretion, subject to any federal and/or state requirements. Signed at (location) City, State Applicant (Company Name) By Authorized Applicant Signature Official Title Witness Date Information about Aetna’s programs for compensating producers is also available at www.aetna.com Agent/Broker Use Only Broker Name SSN Agency Name TIN Pay Commissions to Broker Agency Phone Number Fax Number Street Address City Signature State Date General Agent Name Zip Code E-mail Address Tax ID Phone Number Fax Number Street Address City Signature State Date Zip Code E-mail Address