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of nomas B1ueSbield EMPLOYER APPLICATION �.� O of Florida • Healtb Options. (True Group Application) drop. iroa>�e.eun .wai.. aW aa. ..' aa. SNOW.mena. ❑ New Business 0 Renewal Business Other 1 . Group Information Group # ( BCBSF) : 90000 ( HMO) : A . Name of Group : IINDIAN RIVER COUNTY (BD. OF CTY. COMMISSION) Nature of Business : lGenerall government, nee SIC Code : 9199 Mailing Address : 11840 251111 STREET VERO BEACH, FI, 32960 Email Address : List below Subsidiary or Attiliatecl Uompanies whose employees are to be eligible an included 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 JACORDIA 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 : JUNKNOWN Il . Effective Date/ Eligibility Information A . Effective Date of this Policy shall be 10/04/1996 Effective Date of this Change to the Policy shall be 111/01 /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 = 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 I 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 : 11111 % Dependents : 95 % 13123-995 SR (Rev 0805) 7/17/2006 10: 16:52AM