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lueCross ofRojlda B1ueShield EMPLOYER APPLICATION of Flotda Health Options. (True Group Application) Hmm gEow vA h lawn, @w Craw W UIw9hW W Due e6N '��'lhweedlM B'w Pu er.oe. w EJNew Business 0 Renewal Business Other 1 . Grout) Information Group # (BCBSF) : 90000 (HMO) : A . Name of Group : INDIAN IZIVER COUN'tY (ELECTION SUPVR. I Nature of Business : lGeneral government, nec SIC Code: 9199 Mailing Address: 11840 251- 11 STREET VERO BEACH , Fl , 32960 Email Address : List below Subsidiary or Affiliated Companies whose employees are to be ehgibl_eT_an_d_F7u_d_ea with this application . Name Address B . Applicant hereby applies for issuance of a Group Policy (herein referred to as Policy) by Blue Cross and Blue Shield of Florida, Inc. ( BCBSF) and/or Health Options , Inc. ( HOI ) . Upon acceptance of this application by BCBSF and/or HOI , it will become part of the Policy issued to the applicant named above . C . Prior Health Carrier: Insurance ACORDIA INC. HMO D . The Policy excludes expenses for any service or supply to diagnose or treat any Condition from or in connection with an Insured 's job or employment (e. g. , any service or supply which is covered by Workers ' Compensation insurance ) except for medically necessary services (not otherwise excluded) for an individual who is not covered by Workers' Compensation and that lack of coverage did not result from any intentional action or omission by that individual . The foregoing exclusion applies to an individual who elects exemption from Workers ' Compensation coverage and to an individual who foregoes Workers' Compensation coverage available to employees in the Group. E . Workers Compensation Carrier is : 11UNKNOWN II . Effective Date/ Eligibility Information A . Effective Date of this Policy shall be 10/111 /1996 Effective Date of this Change to the Policy shall be 10/Ill /2006 This Policy may be terminated by the applicant or BCBSF/HOI by giving at least 45 days prior written notice to the other party except in the case of non -payment of Premium . B. Only eligible employees who regularly work a minimum of 30 hours each week and their eligible dependents , shall be eligible for coverage upon the Effective Date of this Policy. C . Specify classification of enrollees for whom coverage is being requested, if other than eligible employees as described in B above. D . New eligible employees may be covered effective on the See Special Instructions after 30 days of employment, so long as the eligible employee submits an application to BCBSF/HOI within 30 days of the date the individual first meets the applicable eligibility requirements . E . At least 75 % of the eligible employees must be enrolled under the Policy on the Effective Date and throughout the term of the Policy and the Group must meet and continue to meet BCBSF/HOI 's participation requirements. F. BCBSF/HOI shall have the right to audit the applicant's payroll records at any time to confirm eligibility for coverage , including participation percentage criteria required by BCBSF/HOI . Applicant agrees to furnish any such request . G . Employer Contribution : Employee : 700 % Dependents : 95 % 13123-995 SR (Rev 0805) 7/17/2006 10: 17.43AM