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oss <br /> .� of Florida <br /> B1ueShield EMPLOYER APPLICATION <br /> � o <br /> Healtbopr;°°,3• (True Group Application) <br /> ❑ New Business 0 Renewal Business Other <br /> 1 . Group Information Group # ( BCBSF) : 90000 (HMO) : <br /> A . Name of Group : JINDIAN RIVER COUNTY (TAX COLLECTORS) <br /> Nature of Business : lGeneral government, nec SIC Code : 9199 <br /> Mailing Address : 1925 14141 LANE VERO BEACH. FL 32960 <br /> Email Address : <br /> List below Subsidiary or Affiliated Companies whose employees are to be e igi a an inc u e with this <br /> application . <br /> Name Address <br /> B. Applicant hereby applies for issuance of a Group Policy (herein referred to as Policy) by Blue Cross and Blue <br /> Shield of Florida, Inc . ( BCBSF) and/or Health Options , Inc. ( HOI ) . Upon acceptance of this application by <br /> BCBSF and/or HOI , it will become part of the Policy issued to the applicant named above . <br /> C . Prior Health Carrier: Insurance JACORDIA INC. <br /> HMO <br /> D . The Policy excludes expenses for any service or supply to diagnose or treat any Condition from or in connection <br /> with an Insured 's job or employment (e. g . , any service or supply which is covered by Workers' Compensation <br /> insurance) except for medically necessary services (not otherwise excluded) for an individual who is not covered <br /> by Workers' Compensation and that lack of coverage did not result from any intentional action or omission by <br /> that individual . The foregoing exclusion applies to an individual who elects exemption from Workers' <br /> Compensation coverage and to an individual who foregoes Workers' Compensation coverage available to <br /> employees in the Group. <br /> E . Workers Compensation Carrier is JUNKNOWN <br /> H . Effective Date/ Eligibility Information <br /> A . Effective Date of this Policy shall be 10/Ul /1996 <br /> Effective Date of this Change to the Policy shall be 10/llf /2006 <br /> This Policy may be terminated by the applicant or BCBSF/HOI by giving at least 45 days prior written notice to <br /> the other party except in the case of non - payment of Premium . <br /> B . Only eligible employees who regularly work a minimum of = hours each week and their eligible dependents , <br /> shall be eligible for coverage upon the Effective Date of this Policy. <br /> C . Specify classification of enrollees for whom coverage is being requested , if other than eligible employees as <br /> described in B above . <br /> D . New eligible employees may be covered effective on the See Special Instructions after = days <br /> of employment, so long as the eligible employee submits an application to BCBSF/HOI within 30 days of the date <br /> the individual first meets the applicable eligibility requirements . <br /> E . At least 75 % of the eligible employees must be enrolled under the Policy on the Effective Date and <br /> throughout the term of the Policy and the Group must meet and continue to meet BCBSF/HOI 's participation <br /> requirements. <br /> F . BCBSF/HOI shall have the right to audit the applicant' s payroll records at any time to confirm eligibility for <br /> coverage , including participation percentage criteria required by BCBSF/HOI . Applicant agrees to furnish any <br /> such request. <br /> G . Employer Contribution : Employee: F-1-071 % Dependents: = % <br /> 13123-995 SR ( Rev 0805) 7/17/2006 10: 17 08A <br />