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1 o Bill V. g EMPLOYER T(True Group APPLICATION 1 Lirwrf�� I III ��II� �III��I� I�I ��I ❑ New Business W Renewal Business ❑ Other: CHANGE IN BENEFITSIRATE3 Group #: [BCBSF) 90000 [HMO) I. APPLICANT INFORMATION A. Name of Grou INDIAN RIVER COUNTY (BD. OF CTY. COMMISSION) Div.# (BCBSF]00f,CO1,R01,002,RO2,003,001,005, R05,006 Nature of Busines General govemment, nee Sic Code: 9199 1 Div.# [HMO] Mailing Address 1840 25TH STREET / VERO BEACH FL 32960 List below Subsidiary or Affiliated Companies whose employees are to be eligible and Included with this applic 40 NAME: N/A ADDRESS B. Applicant hereby applies for coverage/membership through Blue Cross and Blue Shield of Florida, Inc. (BCBSF) and/or Health Options, Inc. (HOI) Group Contract (herein referred to as the Contract). Upon acceptance Of this application by BCBSF and/or HOI, 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. Worker's Compensation carrier UNKNOWN National Union Fire Insurance ® Prior Carrier is: ACORDIAINC. (HMO) IL EFFECTIVE DATE / ELIGIBILITY INFORMATION A. Effective Date of this Contract shall be 10/01/2000 This Contract may be terminated by the applicant or BCBSF/HOI by giving at least 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 B D. Now eligible employees may be covered afte 31ST DAY OF EMPLOYMENT of employment, so tong 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 and fi0 % of the eligible dependents must be enrolled under the Contract on the Effective Date and throughout the term of the Contract. F. Enrollment data Total Ineligible Total Number Percent Multi Option Spli Employee Employees' Eligible Enrolled Enrolled PPO LIMO Employees 1320 0 1320 #Error _ Employees with Dependents 935 0 935 #Error Employer Contribution EMP 100 DEP 95 'Please provide a list of name(s) and reason(s) for Ineligible employees and dependent G. BCBSF/HOI 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. :BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC. ❑ Standard ® Non -Standar HEALTH OPTIONS A. Health Care Benefits Option BC PPO PhyCopay PLGLP704 MANDATED BENEFIT OFFERINGS ❑ Standard ❑ Non -Standar B. Benefits: Co -Ins.: 60 % PPC 60 % Non -PPC (Optional) Applicant has been advised of the A. Health Options Plan $ 200 Deductible Per Person Per Calendar Year following benefit offerings as mandated by the Federal and/or Slate Law. Applicant's $ 400 Family Aggregate Per Calendar Year decision to accept or decline these benefits Is $ $15/$25 Copay: Per Office Visit indicated below: B. Rx CoPay: Accept Decline $ 01400 Per Adm. Deductible For All Non -PPC Hospitals ❑ © Mental & Nervous Disorder _Generic _Brand _NonFonnulary $ 2000/4000 Maximum Out Of Pocket ® E] Alcohol & Drug Dependency C. Vision [:]Yes ©No O ❑ Mammograms Waiver ofi D. Dental Yes q No C. Rx YES BlueScript Copay: $5 Generi $15 Bran $30 NonFormular (Deductible &Coinsurance ❑ ❑ Enteral Formulas PRE EXISTING: till Initial Enrollment Only NO MediScript Oral Contraceptive © Yes ❑ No E.Other SEE SPECIFICATION BENEFITS PAGE D. Dental: ❑ Standard ❑ Non -Standar With Orthodontics ❑ Yes ❑ No DentalEnrollment NIA — A. PremiumstHrepayment fee are payable monthly on or before the due Total date which will be determined: Premium Regular Billing - Employee applications should be submit/ Employee $49,99 thirty (30) days prior to proposed effective dat Employee / Spouse B. Funding Arrangements_ Administrative Services Only Employee / Child(ren . Employee / Family $49.99 HMO: Other Dental Program: Comments: PREMIUM IS PER EMPLOYEE PER MONTH The rales established for this Contract will not be changed for the first twelve (12) months following the initial effective date of Coverage. However, BCBSF/HOI 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 rates 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/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/H01 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 Dale. 5) Collect enrollee contribution, if required, and remit premium payment/prepayment fees to BCBSF/HOI 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. 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. VI. FINAL PREMIUMS, BENEFITS AND EFFECTIVE DATES ARE SUBJECT TO APPROVAL BY BCBSF CORPORATE HEADQUARTERS Issuance of the Contract by BCBSF/HOI will be deemed ceptance of this applical 09-12-2000 t Fran B. Adams, Chairman Dale Signature of Applicant Print / Type Name & Title Daf3 Blue Cross and Blue Shield of Florida, Inc. Licensed Agel`: Agent License Identification Number Blue Cross and Blue Shield of Florida, Inc. and Health Options, Inc. are Independent Licensees of the Blue Crois and Blu, Shield Assoclatlon. (Rev ORFOISTEREDMARK OFTHEBL.UF. CROSS AND BLUHSDIF.LDASSOCIATION. 1312a995SR ( ) sti REGISTERED MAR K OF ll CROSS AND BLUE SLIT ELD OF FLORIDA, INC.