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0 0 0 2f\ 4 bO /O / 111. Illu")10- EMPLOYER APPLICATION 1 (Tru. Group App.) ❑ New Business ® Renewal Business [] Other: CHANGE IN BENEFITS/RATES 1. APPLICANT INFORMATION 1-/ L ento 11 SII Group #: (BCSSFJ 00009 (HMO A. Nem* of Grou INDIAN RIVER COUNTY (BD. OF CTY. COMMISSION) Div.# [BCBSF)001,C01,R01,002,R02,003,001,005, R05,006 Nabs* of Busines WNW nee Sto Code: 9109 Div.# (HMO) Mailing Address 1240 25TH STREET I VERO BEACH FL 32960 List below Subsidiary or Affiliated Companies whose employees are to be eligible and Included with this applic NAME: WA ADDRESS B. Applicant hereby applies for coverage/membership through Blue Cross and Blue Shield of Florida, Inc. (BCBSF) and/or Health Options, Inc. (HOE) Group Contract (heroin referred to as the Contract). Upon acceptance of this application by BCBSF and/or H01, It will become part of the Contract Issued to the applicant named above. C. The Contract benefits do not cover any service or supply to diagnose or treat any Condition resulting from or In connection with a Insured's Job or employment (e.g., any service or supply which is covered by Worker's Compensation Insurance). Benefits will not be provided under the Contract to an Individual who elects and Is statutorily authorized for exemption from Worker's Compensation coverage. D. Werke?. Compensation carrier UNKNOWN National Union Fire Insurance Prior Cartier is: ACORDIA INC. (HMO) 11. EFFECTIVE DATE / ELIGIBILITY INFORMATION A. Effective Date of thls Contract shall be 10/01/2000 . This Contract may be terminated by the applicant or BCBSF/H01 by giving at (east 45 days prior written notice to the other party. B. Only active eligible employees who regularly work a minimum 30 hours each week and their eligible dependents. shall be eligible for coverage upon the Effective Date of this Contract. C. Specify classification of enrollees for whom coverage Is being requested, If other than eligible employees as described in 8 D. New eligible employees may be covered afte 31ST DAY OF EMPLOYMENT of employment, so long as the eligible employee submits an application to BCBSF/H01 within 30 days of the date the Individual first meets the applicable eligibility E. At least 75 % of the eligible employees aryl 60 % of the eligible dependents must be enrolled under the Contract on the Effective Date and Mroughout the term of the Contract. F. 1Enrollment date Total Ineligible Total Number Percent Mulct Option Spli Employee Employees' Eligible Enrolled Enrolled ppO HMO Employees 1320 0 1320 #Error Employees with Dependents 935 0 935 #Error Employer Contribution EMP 100 DEP 95 *Please provide a Iist of name(s) and reason(s) for Ineligible employees and dependent G. BCBSF/H01 shall have the right to audit the applicant's payroll records at any time to confirm eligibility for coverage; applicant agrees to furnish any such records upon request. III. HEALTH PLAN SUMMARY INFORMATION (soled the appropriate box[s]): [BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC. [ 0 Standard ® Non -Standar A. Health Care Benefits Option BC PPO PhyCopay PLGLP704 L MANDATED BENEFIT OFFERINGS 1 B. Benefits: Co -Ins.: 60 % PPC 60 % Non -PPC (Optional) Applicant has been advised of the following benefit offerings as mandated by the S 200 Deductible Per Person Per Calendar Year Federal and/or State Law. Applicant's S 400 Family Aggregate Per Calendar Year decision to accept or decline these benefits Is $ 815/825 Copay: Per Office Visit Indicated below: Accept Decline 8 0/400 Per Adm. Deductible For All Non -PPC Hospitals $ 2000/4000 Maximum Out Of Pocket C. Rx YES BlueScript Copay: 85 Generi 815 Bran $30 NonFornular NO MedlScript Oral Contraceptive © Yes ❑ No El WI © ❑ Alcohol & Drug Dependency Mammograms Waiver of ❑ Deductible a Coinsurance J 0 Enteral Formulas PREEXISTING: Waled initial Enrollment Only Mental & Nervous Disorder r HEALTH OPTIONS ❑ Standard 0 Non -Standar A. Health Options Plan B. Rx CoPay: Generic rm _Brand _Nonfoulary C. Vision ❑Yes ®No D. Dental n Yes WI No E.Other SEE SPECIFICATION BENEFITS PAGE D. Dental: ❑ Standard ❑ Non -Standar With Orthodontics 0 Yes 0 No DentalEnrollment NIA IV. RATE INFORMATION A. Premiums/Prepayment fee are payable monthly on or before the due date which will be determined: Regular Billing - Employee applications should be submit thirty (30) days prior to proposed effective dat B. Funding Arrangements Administrative Services Only HMO: Dental Program: Employee Employee / Spouse Employee / Child(ren Employee / Family $49.99-_ Other Comments' PREMIUM IS PER EMPLOYEE PER MONTH Total Premium $49.99 The rates established for this Contract will not be changed for the first twelve (12) months following the Initial effective date of Coverage. However, BCBSF/H01 may change the rates which are to be effective after this Initial twelve (12) month period of coverage by providing notice to the employer of such changed rata forty-five (45) days prior to their effective date. `V. 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/H01 for this or any other purpose, nor shall BCBSF/HOE 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/HOE 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/HOE 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/H01 as specified above in Section IV. Rates. B. 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. C. My person who knowingly and with Intent to Injure, defraud, or deceive any insurer fifes a statement of claim or an application containing any false, incomplete, or misleading Information Is guilty of a felony of the third degree. (VI. FINAL PREMIUMS, BENEFITS AND EFFECTNE DATES ARE SUBJECT TO APPROVAL BY BCBSF CORPORATE HEADQUARTERS Issuance of the Contractby BCBwSF/H0l will be deemed ceptance of this applicat 09-12-2000 Oats Signature of Applicant Print / Type Name & Title I3ai�_ �lo513oc9 files Cross and -Blue Shield of Fbr4la, Inc. Licensed Ag Agent Li J Fran B. Adams, Chairman 13123996 SR (Rw 3pn lommomar cense Identification Number Mae Cres sed alae Shield of Florida, las. sad Health Options. Ina. are Independeol Licenses of Ik Blue Cron sestinas SNeld Association,. a REGISTERED MARK OF THE SLUE CROSS AND BLUE SHIELD ASSOCIATION. IGISTERED MARE OF BLUE CROSS AND SLUE SHIELD OF FLORIDA, INC. y.