Group Master Application Multiple Employer Plans



|LifeWise Health Plan of Washington | | |

|P.O. Box 91060 | | |

|Seattle, WA 98111-9160 | | |

| | | |

|GROUP MASTER APPLICATION — MULTIPLE EMPLOYER PLANS | | |

|Application is made to LifeWise Health Plan of Washington (hereafter referred to | | | |

|as “we,” “us,” or “our”) for a new Health Care Contract, the provisions of which | | | |

|shall be made available to all eligible classes of employees of participating | | | |

|employers. The multiple employer group shall be called "the group" in this | | | |

|application. | | | |

|New multiple employer groups cannot be enrolled prior to our receipt date of this | | | |

|completed and signed application, which must be accompanied by the initial | | | |

|subscription charge payment. This application and subscription charge payment | | | |

|must be received no less than 10 days prior to the requested effective date. | | | |

| | |GROUP ID |      |

| | |(Completed by LifeWise Health Plan of Washington) |

| | |

|1. |PURPOSE | | |

| | New Group: Complete this application and submit with enrollment forms, and the first month’s payment prior to the effective date of coverage. |

| | Renewal: Complete this application in its entirety. |

| | Other |      |

| |Effective Date: |From       |To       |Annual Contract Renewal Month       |

|2. |GROUP INFORMATION |

| |Note: Please provide a copy of your by-laws, employer eligibility rules, and a sample participation agreement with this application. |

| | |

|A. |Legal Name       |

| |Common Name Note: Required if Legal Name exceeds 50 characters and spaces, otherwise, optional. |

| |  |

| |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. |Tax ID Number       |

|E. |Group Contact Person Mr. Mrs. Ms.       |Title       |

| |Phone No. (   )   -     |Fax No. (   )   -     |E-mail Address       |

|F. |Do you use a COBRA Administrator? No Yes, complete the following: | Same as Billing Address and Contact Person |

| |COBRA Administrator Billing Address       |

| |City       |State    |ZIP       |County       |

| |COBRA Administrator Contact Person Mr. Mrs. Ms.       |Title       |

| |Phone No. (   )   -     |Fax No. (   )   -     |E-mail Address       |

|G. |Is the group a subsidiary of or affiliated with another company or headquartered outside the State of Washington? No Yes, complete the following: |

| |Legal Name       |

| |Physical Address       |

| |City       |State    |ZIP       |County       |

|H. |In the past 36 months have any participating employers in the group filed for protection or operated under Federal/State Bankruptcy laws? No Yes |

| |In the past 36 months has any creditor filed or threatened to file a petition requesting any participating employers in the group to be put into bankruptcy?|

| |No Yes |

|I. |Is the group a union group? | No | Yes |

| |Is the group a trade association? | No | Yes |Trade or other purpose of association |      |

| | |Number of employers in association |      |

| |Is the association a HIPAA “bona fide” association? | No | Yes |Helpful Hint: "Bona fide" is defined in HIPAA regulations at 45 CFR |

| | | | |§144.103. |

|3. |EMPLOYEE ELIGIBILITY REQUIREMENTS (REQUIRED OF ALL PARTICIPATING EMPLOYERS) |

| | | | |

|A. |Minimum Work Hours |

| |Minimum work-hours for full-time employees? |      |hours per       |

| |Minimum work-hours for part-time employees? |      |hours per       |(not less than 20 hrs./wk.) |

| | | | |

|B. |Coverage will end: |

| | Last day of the month for which subscription charge is paid. | Other |      |

| | |

|C. |Domestic Partner Eligibility |

| |Will domestic partners be eligible for coverage? | Never | Yes, for all employers | On a per-employer basis |

| |Will domestic partners be eligible for COBRA? | Never | Yes, for all employers | On a per-employer basis |

| | | | | |

|4. |EMPLOYEE ENROLLMENT |

| | |

| |Total number of employees on payroll regardless of hours worked |      | |

| |Total number of COBRA/Continuation of Coverage subscribers |      | |

| |Calculated Actual % of participation (completed by LifeWise Health Plan of |     % | |

| |Washington) | | |

| | | | |

| |EMPLOYEE PARTICIPATION AND EMPLOYER CONTRIBUTION REQUIREMENTS—TO BE COMPLETED BY LIFEWISE |

|5. |(REQUIRED FOR ALL PARTICIPATING EMPLOYERS) |

| | |

|A. |Minimum Employee Participation Requirement is |     % |

| | |

|B. |Minimum Employer Contribution Requirements | |

| | |

| |Please Note: Waivers of coverage are NOT allowed for eligible employees of non-contributory groups. |

| | |

|1. |Effective date of Contribution: |      (month / day / year) |

| | |

|2. |The participating employer will contribute the following percentage or dollar amount, at a minimum, toward the cost of eligible employee coverage. |

| | |

| |Please Note: If the participating employer differentiates contributions by class of employee, those classes must be represented. |

| | |

| |Employee Medical |      | | |

| |Employee Dental |      | | |

| |Employee Vision |      | | |

| | | | | |

| |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 enrollment requirements are met. |

| | |

|6. |FEDERAL REQUIREMENTS | |

| |

| |Helpful Hint: 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. |

| | |

|A. |Are all participating employers 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 Medicare due to age? |

| | |

| | |Yes. This plan will pay primary to Medicare for all employers as required by federal law. (If group includes potentially exempt (i.e., small) |

| | |employers, underwriting approval is required for this option.) |

| | |

| | |No. (Please provide copies of the election letter and supporting materials filed on behalf of those small employers for whom an exception has been |

| | |elected.) This plan will pay primary to Medicare unless we receive (1) a copy of the election letter and supporting materials for the relevant |

| | |employer(s) and individual(s), or (2) a certification from the group that the group has no participating employer with 20 or more employees as |

| | |defined by the MSP laws. |

| | |

| |Helpful Hint: If a multiple employer group has one or more participating employers that do not qualify as a small employer, then the MSP "working aged" |

| |laws apply to all participating employers within that association and Medicare will pay secondary to the plan unless the group files an election letter on |

| |behalf of its small employers, as described below. A small employer is one that did not employ 20 employees or more (see below for definition) for each |

| |working day in each of 20 or more calendar weeks in either the current or preceding calendar year. |

| |Medicare will pay primary for participating small employers if the group files an election letter (and supporting materials) on behalf of those small |

| |employers with the Medicare Part B carrier in the state in which the employer is headquartered. |

| |"Employees" include all full-time and part-time employees as well as those employees on disability and subject to FICA taxes. Also count leased employees |

| |if they would be counted as employees under §414(n)(2) of the Internal Revenue Code (IRC), and count employees employed by an "affiliated service group" |

| |under IRC §414(m) or by employers considered to be a "single employer" under IRC §52(a) or (b). |

|6. |FEDERAL REQUIREMENTS (CONTINUED) | |

| | |

|B. |Are any participating employers in the group subject to COBRA? |

| | |

| | |Yes |

| | | |

| | |No. Give the legal reason for exemption: |      |

| | |

| |Helpful Hint: 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. In most cases, COBRA applies separately to each participating employer in an association. |

| |"Employees" are full-time and part-time common-law employees. Self-employed workers as defined in IRC §401(c)(1), corporate directors, or independent |

| |contractors should not be counted unless they qualify as common-law employees. "Employees" may also include leased employees who qualify as common-law |

| |employees. Please see COBRA regulations at 26 CFR § 54.4980B-2 Q/A 5 for guidance on counting a part-time employee as a fraction of a full-time employee. |

| | |

|C. |Does the group want to offer COBRA to all participating employers? |

| |

| | |Yes. Underwriting approval required. |

| | | |

| | |No, just to employers subject to COBRA. |

| |

|D. |Are all participating employers 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? |

| | |

| | |Yes. This plan will pay primary to Medicare as required by federal law. |

| | |

| | |No. Group has no participating employers with 100+ employees. |

| | |

| |Helpful Hint: Generally, these laws apply to any multiple employer group that includes at least one employer that employed at least 100 employees on 50% or|

| |more of its working days in the preceding calendar year. There is no exemption for individual employers from these requirements. See the helpful hint in |

| |6A above for a definition of "employee" for this purpose. |

| | |

|E. |Are any participating employers in the group subject to ERISA? |

| | |

| | |Yes |

| | |

| | |No. Give the legal reason for exemption: | Government or Public Plan Church Plan |

| | | Other, please specify: |      |

| | |

| |Helpful Hint: Generally, ERISA applies to all employer health plans except governmental, public or church plans and plans that do not cover any employees |

| |(such as the plan of a self-employed person or a partnership). Non-profit status alone does not exempt an employer from ERISA. |

| | |

|F. |Should the plan be considered a single ERISA plan (not a separate plan for each participating employer)? |

| | | |

| | |Yes. Enter month the ERISA plan year ends: Month |      |

| | | |

| | |No. Each employer has its own ERISA plan. |

| | | |

| |Helpful Hint: Most multiple employer welfare arrangements are deemed to be a separate plan for each participating employer. A very few such arrangements |

| |have obtained a ruling from the Department of Labor that they meet ERISA's commonality and control tests. |

|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 |

|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, the effect of misrepresentations, termination provisions and subscription charge billing administration. |

| |

| |Producer Signature |      |Date       |

| |Producer of Record (Print Name) |      |Producer Number       |

| |E-mail Address |      |Name of Firm/Agency       |

| |Effective Date Producer is Appointed for this Group |      | |

| |Commission: |       PEPM |       % | Scale |

| |

|B. | Split Commission |

| |Secondary Producer Name       |Secondary Producer Number |      |

| | |

| |Commissions are split between the primary and secondary producer as follows (e.g., 50% / 50%): |

| | |

| |Primary       % / Secondary       % |

|9. |GROUP AGREEMENT TO CONTRACT |

| |

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

| | |

|A. |This application becomes part of the contract to provide health care coverage after: |

| | | |

| | |• The application is signed by you; |

| | |• The application is received and approved by us; and |

| | |• We receive the initial month’s subscription 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 also agree to provide notification regarding the |

| |plan’s special enrollment rights to all eligible employees before their enrollment. You attest to have read this application, and certify that all |

| |statements are true and complete. You agree to the terms and obligations stated in this application. It is understood that provisions of the Health Care|

| |Contract, including subscription charges, may be amended or changed from time to time, upon our notice to you. All prior applications, to the extent that|

| |you have not made changes to them in this application, remain in full force and effect. The producer listed in section 8 will remain effective until |

| |written notice is given by either party. We are authorized to pay, on your behalf, commission, if any, for which you are liable to the above named |

| |producer. |

| | | |

|B. |You may elect to allow the producer listed above to 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. These functions may include, but are not limited to: |

| | |

| |• Reinstate Terminated Members |• Inquire on Invoice |• Order ID Cards for an Individual or Whole Family |

| |• Request Invoice |• Inquire on Eligibility |• View Group Demographic Information |

| |• Search for a Member |• Enroll a Member |• Cancel a Member |

| |• View Benefit Detail | | |

| | | | |

| |Do you elect and authorize LifeWise Health Plan of Washington to provide such information to the | No Yes |

| |producer? | |

| | | |

|C. |I affirm that this group has a physical location in the State of Washington, and I am authorized to sign on behalf of the group. |

| |

| |Signature of Group’s Representative       |Date       |

| | | |

| |Group’s Representative (Print Name)       |Title       |

| | | |

| |Please note: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the |

| |company. Penalties include imprisonment, fines, and denial of insurance benefits. |

| |TRACKING INFORMATION—TO BE COMPLETED BY LIFEWISE HEALTH PLAN OF WASHINGTON |

| | |

| |Date Received by Sales       |Information Complete Yes No |Date Missing Information Received |      |

| |

| |Account Manager/Sales Executive       |Extension       |Rep. Code |      |

| |

| |Sales Support Contact       |Extension       |Sales Distribution |      |

| | | | | |

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