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BlucCross ►�� Oofnoridaa B1ueShield EMPLOYER APPLICATION of Flori • Health Options. (True Group Application) Nwn aaan w b �+r. ao.c a.ma ex.awi W BIw6NnICIaNnlm. V1 . Applicant Responsibilities A . The applicant shall : 1 ) Notify each enrollee to the benefits selected by the applicant, their Effective Date , and the termination date of coverage ( in this regard , applicant acts as the agent of the enrollee, and in no event shall the applicant be deemed an agent of BCBSF/HOI for this or any other purpose, nor shall BCBSF/HOI be responsible for such notification to retirees ) . 2) Deliver to covered enrollees identification cards and certificates of coverage furnished by BCBSF/HOI . 3) Notify BCBSF/HOI promptly of any changes in the eligibility of enrollees covered under this Agreement . 4) List any absentees at the time of initial enrollment on the appropriate BCBSF/HOI form . Applications from absentees will be accepted at BCBSF/HOI Corporate Headquarters no later than thirty (30) days from the group's Effective Date. 5) Collect enrollee contribution , if required , and remit Premium payment/prepayment fees to BCBSF/HOI as specified in this application . B . By choosing the HSA Banking Arrangement , if applicable, I authorize BCBSF to exchange certain limited information , for employees enrolling in a high deductible health plan designed for use with an HSA, with BCBSF's preferred bank, for the purposes of initial enrollment in and administration of , HSAs . I recognize that BCBSF does not provide banking services and that BCBSF is not responsible for the provision of HSA services . HSA services are provided by the bank of your choice subject to the terms and conditions of such arrangements , including fees the bank may charge. C . Applicant hereby establishes an Employee Welfare Benefit Plan for the purpose of providing for its employees or their beneficiaries medical , surgical , hospital care, or benefits in the event of sickness. D . 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 . Vll . Final Premiums, Benefits and Effective Dates are Subject to Approval by BCBSF Corporate Headquarters Issuance of the Policy by BCBSF/HOI will be deemed acceptance of this application . Date Signature of Applicant Print/Type Name K Title ak- Jose h A . Baird County Administrat r Date ue Cross and Blue 1d of Florida. Inc . and/or Health Options, Inc . Licensed Agent (Print) Signature of Agent Agent License Identification Number APPROVED AS TO FORM AND L GALS FFIC0XV CY B WILLIAM WDKRAAL ASSISTANT COUNTY ATTORNEY 13123-995 SR (Rev 0805) 7/17/2006 10: 17:43AM