IDO NOT STAPLE)

IDO NOT STAPLE) Ad d rep/ tri Pahn ID/ B. Waiver of Coverage I decline all coverage for: Myself %Spouse tDependent Children Myself and all dependents Employee Enrollment Form Virgin Islands To speed the enrollment process, please be thorough and till out all sections that apply. UnitedHealthcare To Be Completed by Employer Requested Effective Date of Coverage/Date of Chang Group Name Policy Number Date of Hire oto / 0/Awf Reason for Application New Group Plan ki New Hire Employee Type (Check all that apply) Positiontritle executive assi.t Ian Life EventrDate Annual Open VActive COBRA c: State Continuation Stan dt Status Change Hours Worked per week Dependent Add/Delete • Change Name/Address Enrollment [; Late End di__ Hourly Salary Part time to Full time Enrollee Union Non-Union n Retired Salary $10,00. 00Required only it Life. STD. Waiving Coverage Other Termination Other or LTD Plan based on salary A. Employee Information If you are waiving all coverage. please complete sections A and B. Last Name First Name MI N/4 - Social Security Number Address , dhio0,4 liteartert, hige /j -3 State Zip Code &of& Home/Cell Phone AP city ___ 41-tomaj Date of Birth On 37/S5 Gender n M rJF Marital Status Ei Single ,i4Aarried n Divorced o Widowed Work Phone Language Preference, if not English Email Address Do you use tobacco?' Yes rirl40 If yes, are you currently participating in a tobacco cessation program or do you intend to join one? o Yes o No Primary Care Dentist Dentist First 8, Last Name p,.ofti, do _sraroacliaro IDS Existing Patient? &?es °No Existing Patiegt? /0)..s ,. No Prim* Care Physician' Physician First & Last 1- 7;6 Yro o /au Haar Olth.el €.41 I -1 .39-49/ Declining coverage due to existence of other coverage: Spouse's Employers Plan Individual Plan Covered by Medicare Medicaid COBRA from Prior Employer VA Eligibility Tn-Care I (we) have no other coverage at this time Other I understand that by waiving coverage at this time, I will not be allowed to participate unless I qualify at a special enrollment period or as a late enrollee, if applicable, or at the next open enrollment period. Date frO Employee Signature if waiving all coverage Coverage Provided by 'UnitedHealthcare and Affiliates": Medical coverage provided by UnitedHealthcare Insurance Company Dental coverage provided by UnitedHealthcare Insurance Company Lite. Short-Term Disability (STD), Long-Term Disability (LTD) Insurance coverage provided by UnitedHealthcare Insurance Company Vision coverage provided by UnnedHealthcare Insurance Company so EL16V1 4115 Page I of 4 6554062 11,15 EFTA00520760 Employee Name x/4 C. Family Information LW All Enrolling (Attach sheet il necessary) / / A ll Relationship. Last Name First Name MI Sex c.; M ii F Date of Birth Spouse / / /Domestic Partner Social Security Number I I I — I i I — 1 I I I Do you use tobacco? o Yes n in a tobacco cessation program or No If yes. do you are you intend to gin currently participating one? Yes No Primary Care Physician' Existing Patient? Yes Physician Firs & Last Name No Primary Care Dentist' Dentist First & Last Name Existing Patient? Yes No Address IDS IDS Relationshipi Last Name First Name MI Sex o M 0 F Date of Birth / / Dependent Social Security Number I I I — I I I — I I I I Do you use tobacco? • Yes in a tobacco cessation program or No If yes, are you do you intend to join currently participating one? • . Yes . No Primary Care Physician' Existing Patient? 0 Yes Physician First & Last Name u No Primary Care Dentist' Dentist First & Last Name Existing Patient? c Yes o No Address ID/ IDS — Permanently disabled and age 26 or older' 7: Yes o No Relationship' Last Name First Name MI Sex o M F Date of Birth / / Dependent Social Security Number I I I — I I I — I I I 1 Do you use tobacco? 0 Yes c No If yes. are you currently participating in tobacco cessation program or do you intend to join one? 0 Yes o No Primary Care Physician' Existing Patient? ,..❑] Yes .) No Physician Firs & Last Name Primary Care Dentist' Existing Patient? 0 Yes a No Dentist First & Last Name Address ID/ IDS — Permanently disabled and age 26 or older' o Yes a No Relationship' Last Name Fi st Name MI Sex .. M o F Date of Birth / / Dependent Social Security Number I I I — 1 I 1 — I I I I Do you use tobacco? a Yes : ] No If yes, are you currently participating in a tobacco cessation program or do you intend to join one? : Yes 1: No Primary Care Physician' Existing Patient? c Yes 0 No Physician First & Last Name Primary Care Dentist' Existing Patient? a Yes a No Dentist First & Last Name Address ID/ IDS — Permanently disabled and age 26 or older' . • Yes 0 No Relationship' Last Name I First Name MI Sex i3M0F I Date of Birth / / Dependent Social Security Number 3 I I I - I 1 I -1 I I I Do you use tobacco?' o Yes a No If yes. are you currently participating in a tobacco cessation program or do you intend to join one? .. Yes : • No Primary Care Physician' Existing Patient? c Yes t, No Physician Firs & Last Name Primary Care Dentist' Existing Patient? :_) Yes c No Dentist First & Last Name Address IDS IDS — Permanently disabled and age 26 or older' i Yes :. I No (1) Tobacco means all tobacco products. including. but not limited to. cigarettes cigars, and chewing tobacco. You should only check the "yes* box above if tobacco was used four or more times per week on average (excluding religious or ceremonial use) within the past 6 months by someone of legal age to purchase tobacco in the state of residence (2) For UnitedHea/thcare Corrpass. Navigate. Select, Select Plus. and other products requinng you to choose a Pnmary Care Physician (PCP), you must use the UnitedHealthcare directory of providers to choose a PCP for yourself and each of your covered dependents. (3) Please see employer representative as some dental plans require a Primary Care Dentist (PCD) selection. (4) For court ordered dependent, legal documentation must be attached If a dependent does not reside with eligible employee, please provide address on a separate sheet. (5) If you answered 'Yee for Disabled and the dependent child is 26 years of age or older, unmarried. ale* dependent upon subscnber for support and is not able to be sett- supporting because of a physically or mentalh disabling intury, illness or condition, please attach a medical certification of disability. Page? of 4 EFTA00520761 Employee Name D. Product Selection Please check the box for each coverage in which you or your dependents are enrolling. If your employer offers a choice of plans, indicate which plan selecting. Indicate the dollar amount selected for the Life and Accidental Death & Dismemberment ( . Supplemental Life. Short-Term Disability (STD), and Long-Term Disability (LTD) plans. Benefit offerings r ependent upon employer selection. Person Medical Dental Vision Basic Life= Supp Employee K 0 ❑$ Spouse/Domestic Partner 0 o$ c; $ K $ $ Dependent 0 Person STD LTD Employes 0 0 Life Insurance Beneficiary Full Name and Address Ol whine for LIN Insurance with Unnedftalthniel Relationship Primarypc t2oo Go SeconciarYti4090 CAOldiaL -Th ethfrn? n ititi nke efe,e k >2O1,,aasfewr,:rj v O mor%e•- itit:Isk, ted;-`,:s ildelato &J oe. LI a Se a t E. Prior Medical Insurance Information Within the last 12 months, have you, your spouse, or your dependents had any other medical coverage? VNO o YES yes. please complete this section.) Prior medical carrier name Prior coverage type: 0- Employee c Spouse o Child(ren) o Family F. Other Medical Coverage Information Effective date End date This section must be completed. (Attach sheet If necessary.) On the day this coverage begins, will you, your spouse or any of your dependents be covered under any other medical health plan or policy. including another UnitedHealthcare plan or Medicare? c: YES (continue completing this section) AACI (skip the rest of this section) Other Group Medical Coverage Information (only list those covered by other plan) Type (BISN)' Effective Date MM/DDNY End Date MWDD/YY Name and date of birth of policyholder for other coverage Employee: Spouse Name: Dependent Name Dependent Name: Dependent Name: 'B.Enter '8' when this dependent is covered under both you and your spouse's insurance plan (married) S.Enter 'S' if you are the parent awarded custody o this dependent and no other •ndividual is required to pay for this dependent's medical expenses. F. Enter 'F' if this dependent is covered by another individual (not a member of your household) required to pay for this dependent's medical expenses. Medicare — Employee Information: II enrolled in Medicare. please attach a copy of your Medicare ID card. 0 Enrolled in Part A. Effective Date 0 Ineligible for Part A' o Not Enrolled in Part A (chose not to enroll)• o Enrolled in Part B. Effective Date o Ineligible for Part B' n Not Enrolled in Part B (chose not to enroll)• • Enrolled in Part D: Effective Date o Ineligible for Part D' o Not Enrolled in Part D (chose not to enroll)' • Reason for Medicare eligibility: o Over 65 o Kidney Disease o Disabled o Disabled but actively at work Are you receiving Social Security Disability Insurance (SSDI)? o YES o NO Start Date Medicare — Spouse/Dependent Name: o Enrolled in Part A: Effective Date c Ineligible for Pail A' o Not Enrolled in Part A (chose not to enroll)" u Enrolled in Part B: Effective Date c Ineligible for Part B' LI Not Enrolled in Pail 8 (chose not to enroll)• • o Enrolled in Part D: Effective Date n Ineligible for Part D• n Not Enrolled in Part D (chose not to enroll) •' Reason for Medicare eligibility: o Over 65 o Kidney Disease Disabled :: Disabled but actively at work 'Only check 'Ineligible' it you have received documentation from your Social Security benefits that indicate that you are not eligible for Medicare. •• If you are eligible for Medicare on a primary basis (Medicare pays before benefits under the group policy), you should enroll in and maintain coverage under Medicare Part A, Part B. and/or Part D as applicable. Page 3 of I EFTA00520762 G. Signature Your enrollment in the plan is expressly conditioned upon your acceptance of all terms and conditions contained in this enrollment application If you do not agree to the following terms and conditions, you may not complete your enrollment. TERMS AND CONDITIONS As a condition of my and/or my dependents' participation in the plan, and in consideration for the privileges that come from participation in the plan. I hereby agree for myself and/or for my dependents as follows: I recognize and understand that the plan contracts with physicians and other providers that make up the plan network. I recognize that all physicians and other providers that participate in the plan network are subject to credentialing under applicable State regulations and pursuant to the plan's network credentialing process. I understand that such credentialing includes a review of provider education, training and licensure. However, by participating in the plan I hereby acknowledge and accept that the plan is not a provider of medical services, and I am aware that obtaining or not obtaining medical care involves significant risks such as serious injury and even death. I acknowledge that the credentialing of physicians and other providers does not in any way reduce this risk. I agree to assume all risks and responsibility for, and hold the plan harmless from. any and all claims for damages. including personal injury or death, medical expenses, disability, lost wages, and loss of earning capacity which may be incurred or associated with medical treatment obtained through a participating physician or other provider. I recognize that all physicians and other providers that participate in the plan network are independent contractors and not the plan's employees or agents and are solely responsible for any malpractice, adverse outcomes, or any other claims arising from medical treatment rendered to me and my dependents. I HEREBY AGREE THAT THE PLAN IS NOT RESPONSIBLE NOR LIABLE FOR ANY ADVICE, COURSE OF TREATMENT, DIAGNOSIS OR ANY OTHER INFORMATION, SERVICES OR PRODUCTS THAT I OR MY DEPENDENTS OBTAIN THROUGH A PARTICIPATING NETWORK PHYSICIAN OR OTHER PROVIDER. I recognize and understand that the plan does not recommend. endorse or make any representation about the appropriateness or suitability of any specific tests, products, procedures, treatments, services, or opinions. I recognize that the plan, plan documents. and any health and wellness information provided by the plan, are not intended or implied to be a substitute for professional medical advice, diagnosis or treatment I agree to confirm any medical information obtained from or through the plan with other sources, and will review all information regarding any medical condition or treatment with my physician. I HEREBY AGREE TO NEVER DISREGARD PROFESSIONAL MEDICAL ADVICE OR DELAY SEEKING MEDICAL TREATMENT BECAUSE OF SOMETHING I HAVE READ OR ACCESSED THROUGH THE PLAN. I authorize UnitedHealthcare Insurance Company and its affiliates (collectively, 'UnitedHealthcare') to obtain, use and disclose my medical, claim or benefit records, including any individually identifiable health information contained in these records. I understand these records may contain information created by other persons or entities (including health care providers) as well as information regarding the use of drug, alcohol. HIV/AIDS, mental health (other than psychotherapy notes). sexually transmitted disease and reproductive health services. I authorize any health care provider, pharmacy benefit manager, other insurer or reinsurer, hospital, clinic or other medical facility, health care clearinghouse, and any of their affiliates. representatives or business associates, to disclose my information to UnitedHealthcare and Affiliates. I understand that the purpose of the disclosure and use of my information is to allow UnitedHealthcare to facilitate the appropriate management of treatment, services, payment and benefits. I further understand that the information disclosed will not be used for purposes of eligibility, enrollment, underwriting and premium risk rating. I understand this authorization is voluntary and I may refuse to sign the authorization. I understand I may revoke this authorization at any time by notifying my UnitedHealthcare representative in writing, except to the extent that action has already been taken in reliance on this authorization. As required by HIPAA. UnitedHealthcare also requires that I acknowledge the following, which I do: I understand that information I authorize a person or entity to obtain and use may be re-disclosed and no longer protected by federal privacy regulations. This authorization, unless revoked earlier, expires 30 months after the date it is signed. I understand that I am completing a joint fife and health application and that each response must be complete and accurate. I (we) request the indicated group medical coverage. I authorize any required premium contributions to be deducted from my earnings. I (we) have not given the agent or any other persons any required information not included on the application. I (we) understand that UnitedHealthcare is not bound by any statements I (we) have made to any agent or to any other persons, it those statements are not written or printed on this application and any attachments. Please note that it you leave out information or make a misrepresentation on this form we may be allowed by law to take one or more of the following actions: terminate or non-renew your coverage or change your premium retroactively to the date your policy became effective. Please maintain a copy of this authorization for your records. Date Employee /O/An r all applying H. Census Interim:Am (optional) ouse Signature (if applying for coverage) NOTE: Responding to this question is optional and is not required. Data collected in this section will be used only to help communicate with enrollees and inform them of specific programs to enhance their well-being. This information will not be used in the eligibility process. 1. Race, check all that apply: K White o Black, African-American L; American IndiarVAlaska Native .: Asian K Native HawaiimVPacific Islander 7' Other Race. please specify 2. Are you of Hispanic or Latino origin? K Yes s No Page 4 of 4 EFTA00520763