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B1ueCross B1ueShield ofnorida EMPLOYER APPLICATION • • Health options. (True Group Application) .e a.sm.ie .®ena. 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/H01 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 . V 11 . 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 Siguanirc of Applic/a�nt Print/Type Name & Title =)atcluc A &L&4 Joseph A . Baird Count Administra or lue Shi Id of Florida, Inc . and/or Health Options, Inc. Licensed Agent (Print) Signature of Agent Agent License Identification Number APPROVED AS TO FORM ANDpJLEGALSUFFI C/ BY r+� r WILLIAM K . DEBRAAL ASSISTANT COUNTY ATTORNEY 13123-995 SR ( Rev 0805) 7/17/2006 10: 16:52AM