LARGE EMPLOYER / GROUP AGREEMENT

/
51 OR MORE EMPLOYEES
Application is made to LifeWise Health Plan of Oregon (hereafter referred to as “we,” “us,” or “our”) for a new MasterGroup Contract, the provisions of which shall be made available to all eligible classes of employees.
Your group cannot be enrolled prior to our receipt dateof this completed and signed application, which must be accompanied by enrollment forms and the initial premium payment.

GROUP ID

(Completed by LifeWise)
1. / EFFECTIVE DATE
A. / From: / To:
B. / Renewal Notification / 90 days / 120 days / Other
2. /

GROUP INFORMATION

A. / Legal Name
Physical Address
City / State / ZIP / County
B. / Mailing Address / Same as Physical Address / Separate Address, complete the following:
Street/ P.O.
City / State / ZIP / County
C. / Billing Address / Same as Mailing Address / Same as Physical Address: / Separate Address, complete the following:
Street/ P.O.
City / State / ZIP / County
Billing Contact Person Mr. Mrs. Ms. / Title
Phone No. ()- / Fax No. ()- / E-mail Address
D. / Employer Identification Number (EIN)
Type of Business / SIC # / NAICS #
Association Plans Only: Is the association filed and approved with the Oregon Insurance Division as a group policyholder? / No Yes
E. / Contact Person Mr. Mrs. Ms. / Title
Phone No. ()- / Fax No. ()- / E-mail Address
F. / Is the group a subsidiary of or affiliated with another company or headquartered outside the State of Oregon?
No Yes, complete the following:
Legal Name
Physical Address
City / State / ZIP / County
G. / Worker’s Compensation /State Industrial Carrier / Policy #
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3. / BENEFITS SELECTED
Class / Office
Visit
Copay / Individual Deductible / Coinsurance
(i.e. 90 / 70) / Vision / Alternative Care / Individual Maximum
Coinsurance Maximum
(Copay plans only)
Preferred
Providers / Non-Preferred
Providers
Class / Prescription Drugs / Dental / Orthodontia
Clarifications:
LWO 2007 LATAPP.LG / 014718 (Rev 10-2010) / RE EMPLOYER / GROUP AGREEMENT / PAGE1 OF 6
4. / EMPLOYEE ELIGIBILITY REQUIREMENTS
A. / All employees who work a minimum of / hours per
All part-time employees working a minimum of /

hours per

/

(not less than 20 hrs./wk.)

Only those employees in a specific classor classes, working a minimum of /

hours per

Specify class: / All Employees / Management / Salaried / Hourly / Part-time / Full-time / Retiree*
Early Retiree* / Union / Non-Union / Other, please specify
B. / Employee Eligibility Waiting Period Information
All eligible employees are effective on the:
1. / 1st of the month following or Next day following:
30 days / 60 days / 90 days / 180 days / 365 days*
2. / 1st of the month following date of hire / Exact date of hire / Other*
C. / Waive Eligibility Waiting Period*
Waive the eligibility waiting period on all current qualifying employees.
Apply the eligibility waiting period to all employees (current qualifying employees must satisfy the probationary period).
D. / Domestic Partner
1. / Will unregistered Domestic Partners be eligible for enrollment?* / No Yes
2. / Will domestic partners (registered and/or unregistered) be eligible to make an independent election for COBRA as a qualified beneficiary? / No Yes
3. / Will domestic partners (registered and/or unregistered) be eligible for COBRA only when the employee elects COBRA continuation? / No Yes
* Requires Underwriting approval
5. / EMPLOYER CONTRIBUTION LEVEL
The employer will contribute the following percentage or dollar amount toward the cost of eligible employee and dependent coverage.
Contribution for Employees: / Medical Plan / Dental Plan
Contribution for Dependents: / Medical Plan / Dental Plan
Note: If the Employer contribution towards the cost of any tier of coverage has decreased by more than 5 percentage points since March 23, 2010, the plan ceases to be grandfathered.
Please Note: We reserve the right to review payroll records or comparable reports to ensure that eligibility and
enrollmentrequirements are met.
6. / FEDERAL REQUIREMENTS
We strongly urge you to consult legal counsel in answering the questions below. The summaries below are not intended to be or to replace legal advice on your particular group. It is the group’s responsibility to inform LifeWise immediately if facts change which would cause the group’s answers below to change. For more information, you may contact Employee Benefits Security Administration (EBSA) at 1-866-444-3272.
A. / Is the group subject to the federal Medicare Secondary Payer (MSP) laws that prohibit discrimination against individuals with group coverage based on their (or a spouse’s) current employment status who have
Medicaredue to age?
1. / Yes. / This plan will pay primary to Medicare as required by federal law.
No. / Under 20 employees.
2. / Please also provide the number of employees who now meet Medicare’s definition of “employee.”
These laws do not apply to any employer who did not employ 20 employees or more for each working day in each of 20 or more calendar weeks in either the current or preceding calendar year. For these small group plans, Medicare pays primary to the group plan.
B. / Is the group subject to the federal Medicare Secondary Payer (MSP) laws that prohibit discrimination against individuals with group coverage based on their (or a family member’s) current employment status who have Medicare due to disability?
1. / Yes. / This plan will pay primary to Medicare as required by federal law.
No. / Under 100 employees.
2. / Please also provide the number of employees who now meet Medicare’s definition of “employee.”
Generally, these laws apply to any employer that employed at least 100 employees on 50% or more of its working days in the preceding calendar year.
C. / Is the group subject to COBRA?
Yes.
No. / Give the legal reason for exemption:
Generally, these laws apply to any non-church employer that employed 20 or more employees on at least 50% of its working days in the preceding calendar year.
D. / Is the group subject to ERISA?
Yes. Enter the month the ERISA plan year ends: Month
No. Give the legal reason for exemption: / Government or Public Plan Church Plan
Other, please specify:
Generally, ERISA applies to all employer health plans except governmental, public or church plans.
Non-profit status alone does not exempt an employer from ERISA.
7. / CURRENT COVERAGE INFORMATION
A. / Is this plan intended to replace any existing coverage?
No, go to section 7B / Yes
Name(s) of prior Medical carrier(s) / Name(s) of prior Dental carrier(s) / Name(s) of prior Vision carrier(s)
Termination date / Termination date / Termination date
7. / CURRENT COVERAGE INFORMATION (continued)
B. /
Are you offering a plan from a carrier other than LifeWise?
No, go to section 8
/
Yes, more than one carrier’s plan is offered:
Name(s) of other Medical carrier(s) / Name(s) of other Dental carrier(s) / Name(s) of other Vision carrier(s)
Indicate if other plan is an HSA.
HSA?
No
Yes
No
Yes
No
Yes
8. / Producer AGREEMENT TO CONTRACT
A. / You, the producer(s), certify that you have met with the group submitting this agreement and that you have fully explained its contents. You have discussed coverage, eligibility, any pre-existing condition waiting periods, the effect of misrepresentations, termination provisions and premium charge billing administration.
Producer Signature
/ Date
Producerof Record (Print Name) / ProducerNumber
E-mail Address / Name of Firm/Agency
Producer Phone / Producer Fax
Effective Date Producer is Appointed for this Group
Commission: / PEPM / % / Scale
B. / Split Commission
Secondary ProducerName / Secondary ProducerNumber
Commissions are split between the primary and secondary producer as follows (e.g., 50% / 50%):
Primary % and Secondary %
9. / GROUP AGREEMENT TO CONTRACT

You, the group named in section 2 of this agreement, understand and agree to the following.

A. /

This agreement becomes part of the contract to provide health care coverage after 1) the application is signed by you; 2) the application is received and approved by us; and 3) we receive the initial month’s premium charges.

You may not assign this contract without our written consent. Any attempt to do so will not have any binding effect on us. You agree to promptly deliver materials and notifications, including benefit booklets, received from us, to all covered employees. You attest to have read this agreement, and certify that all statements are true and complete. You agree to the terms and obligations stated in this agreement. The producer listed in section 8 will remain effective until written notice is given by either party.
B. / You may elect to allow the producer listed in section 8to act as a group benefit administrator beginning on the group’s effective date. This means that the producer/administrator will be able to access membership and billing functions, and obtain information about group members via the Web on behalf of the group.
Do you elect and authorize LifeWise to provide such information to the producer? / No Yes
C. / I affirm that this group has a physical location in the state of Oregon, and I am authorized to sign on behalf of the group.I understand and agree that no producer has the authority to waive a complete answer to any question, make or alter any contract or waive any of our rights or requirements.
Signature of Group’s Representative / Date
Group’s Representative (Print Name) / Title
10. / EMPLOYEE ENROLLMENT ( FOR INTERNAL USE ONLY)
A. /

Total number of employees

/

G.

/

Total number of retirees eligible for benefits

on payroll regardless of hours worked / (if applicable)
Note: For 10B and 10C, count each employee in only ONE category. / H. / Total number of COBRA members
B. / Employees not eligible to enroll
I. / Do you have eligible employees employed outside the
1. / Employees who work less than the minimum hours hours per week (as specified in section 4A / State of Oregon?
per week (as specified in section 4A)
No / Yes, complete the following table:
2. / Employees who are temporary or seasonal
(unless underwriting approved eligibility) / Number of
State/Country / Employees
3. / Employees who are in an eligibility waiting period
4. / Employees who are not in a covered class
(employees not specified as eligible in 4A)
Total 10B
C. / Employees not enrolling due to coverage under:
1. / A Government plan
(e.g., Medicare, Champus/Tricare, Military)
2. / Other group coverage
3. / A collective bargaining agreement (Union)

Total 10C

D. / Total number of employees eligible to enroll
(section 10A - 10B - 10C)
E. / Eligible employees waiving enrollment without other coverage
J. / Calculated Actual % of participation
F. / Total number of eligible employees enrolling (section 10D - 10E)
LWO 2007 LATAPP.LG / 014718 (Rev 10-2010) / RE EMPLOYER / GROUP AGREEMENT / PAGE1 OF 6