C15390-H (1/18) Employee enrollment application (for 101+ employees) Page 1 of 4

Health Plan Employee Enrollment Application Blue Shield plans for 101+ employees

Blue Shield of California and Blue Shield of California Life & Health Insurance Company (Blue Shield Life)Please note: Failure to complete this enrollment application legibly and completely may result in a delay in the enrollment process.

Reason for application: New hire

Rehire date

____________

Loss of coverage date ____________ Open enrollment

Late enrollment

Other qualifying event type______________________ Date above event occurred __________

Section 1 – Important enrollment guidelines for Specialty Benefits coverage

Dental and vision insurance – An employee may enroll in a dental and/or vision plan without enrolling in a health plan. In order for a dependent to enroll in a dental or vision plan, the employee must be enrolled in the same dental or vision plan.

Section 2 – Plan(s) Select and fill in plan name(s) as appropriate.Medical benefits without ABHP (account-based health plan) plan options:

Access+ HMO __________________ Access+ HMO SaveNetSM __________ Local Access+ HMO ______________ Added Advantage POSSM ___________ Trio HMO ______________________ Active Choice 1 __________________ Full PPO _______________________ Full PPO Savings2 _________________ Tandem PPO ____________________ Tandem PPO Savings ______________ Full PPO ASO/Full PPO ASO Savings2

_____________________________ Blue Shield 65 PlusSM (HMO)

Medical benefits with ABHP (account-based health plan) plan options:

Access+ HMO: HRA HIA FSA

Active Choice1: HRA HIA FSA

Local Access+ HMO: HRA HIA FSA

Full PPO: HRA HIA FSA

Full PPO Savings2: HSA HRA HIA FSA HSA LPFSA3

Full PPO ASO: HRA HIA FSA

Full PPO ASO Savings2: HRA HIA LPFSA3 HSA FSA

Specialty Benefits Dental PPO ____________________________ Dental HMO ___________________________ Vision1 ________________________________ Other _________________________________

1 Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life).

2 Full PPO Savings plans are HSA-eligible high-deductible health plans.

3 Must be paired with an HSA plan only

Note: Blue Shield does not offer tax advice nor do we offer HSAs, HRAs, HIAs, FSAs, or LPFSAs.

Internal use only. Do not write in this section and skip to Section 3.

Department code Group ID Subgroup ID Class ID Effective date _______________

C15390-H (1/18) Employee enrollment application (for 101+ employees) Page 2 of 4

Section 4 – Dependent spouse/domestic partner/children information If you, your spouse/domestic partner, or your dependents are refusing coverage, please complete and sign the Refusal of Coverage form.

Dependent’s address, if different from employee’s address – please indicate which dependent(s) this applies to:

Enrolling spouse/domestic partner information

Enroll in (please check all that apply)

Access+ HMO and Added Advantage POS only – name of Personal Physician Dental HMO only – dental provider

c Spouse c Domestic partner c Male c Female

First MI

Last

Social Security number

Date of birth (mm/dd/yyyy)

c Medicalc Dentalc Vision

Doctor’s name

First

Last

Provider number

IPA/medical group name

IPA/medical group number

Dental provider name

First

Last

Dental provider number

Existing patient? c Yes c No Existing patient? c Yes c No

Enrolling dependent child(ren) information

Enroll in (please check all that apply)

Access+ HMO and Added Advantage POS only – name of Personal Physician Dental HMO only – dental provider

c Male c Female

First MI

Last

Social Security number

Date of birth (mm/dd/yyyy)

c Medicalc Dentalc Vision

Doctor’s name

First

Last

Provider number

IPA/medical group name

IPA/medical group number

Dental provider name

First

Last

Dental provider number

Disabled? c Yes c No Existing patient? c Yes c No Existing patient? c Yes c No

Section 3 – Employee information

Social Security number Employer (group) name

Last name First name MI

Employment status:

c Full time c Part time c Retiree Date of hire: ____________________

Job title/classification

Home address (street, city, state, ZIP code)

Mailing address (if different from home address)

Home phone number Email address

How would you prefer we contact you? c Email c Standard mail c Telephone

Date of birth ____________________ Gender c Male c Female Marital status c Single c Married c Domestic partner

Language preference: c English c Spanish c Chinese c Vietnamese c Other __________

Are you enrolling your spouse/domestic partner and/or child dependents c Yes c No If “yes,” complete Section 4 of application.

HMO provider information: Blue Shield of California directory website: blueshieldca.com/fap/app/search.html

Name of primary care physician (PCP): Provider number:

IPA/medical group name: IPA/medical group number: Existing patient? c Yes c No

Name of dental provider: Dental provider number: Existing patient? c Yes c No

Section 5 – Medicare information

1. Are you or any of your dependents currently covered by Medicare? c Yes c No If “yes,” please attach a copy of your Medicare card(s) and/or select the type of coverage below: Part A: c Effective date: ______________ (mm/dd/yyyy) Part B: c Effective date: ______________ (mm/dd/yyyy) 2. Is Medicare eligibility due to end-stage renal disease (ESRD)? c Yes c No If “yes,” please answer the following questions: a) What was the first date of dialysis treatment, and what type of dialysis are you receiving? Date _______________ Type: c Hemo c Self-dialysis (peritoneal) b) If you have had a kidney transplant, what was the date of the transplant: ______________ (mm/dd/yyyy)

Section 6 – Authorization The following authorization section is to be signed by all employees applying for coverage with Blue Shield of California or Blue Shield of California Life & Health Insurance Company (“Blue Shield Life”). This enrollment cannot be processed without your signed authorization.

I agree: All information on this form is correct and true to the best of my knowledge and belief. I understand that it is the basis on which coverage may be issued under the plan. I understand that if I have committed fraud or made an intentional misrepresentation of any material fact in conjunction with this application Blue Shield of California/Blue Shield Life may pursue one of the following remedies within the first 24 months of coverage: my coverage may be canceled, or following 30-day notice, rescinded. I understand that coverage does not become effective until this and my employer’s application have been approved by Blue Shield of California/Blue Shield Life.

Signature of employee_______________________________________________________________ Date _________________________

Print employee name _____________________________________________________________________________________________

I further authorize my employer to deduct from my earnings the contribution (if any) required toward the cost of this plan.

Signature of employee ___________________________________________________________ Date __________________________

Print employee name ___________________________________________________________________________________________

C15390-H (1/18) Employee enrollment application (for 101+ employees) Page 3 of 4

Enrolling dependent child(ren) information

Enroll in (please check all that apply)

Access+ HMO and Added Advantage POS only – name of Personal Physician Dental HMO only – dental provider

c Male c Female

First MI

Last

Social Security number

Date of birth (mm/dd/yyyy)

c Medicalc Dentalc Vision

Doctor’s name

First

Last

Provider number

IPA/medical group name

IPA/medical group number

Dental provider name

First

Last

Dental provider number

Disabled? c Yes c No Existing patient? c Yes c No Existing patient? c Yes c No

c Male c Female

First MI

Last

Social Security number

Date of birth (mm/dd/yyyy)

c Medicalc Dentalc Vision

Doctor’s name

First

Last

Provider number

IPA/medical group name

IPA/medical group number

Dental provider name

First

Last

Dental provider number

Disabled? c Yes c No Existing patient? c Yes c No Existing patient? c Yes c No

Disclosure of personal and health informationAt Blue Shield of California/Blue Shield Life, we understand the importance of keeping your personal information private, and we take our obligation to do so very seriously. We are required by law to maintain the privacy and security of your personal information in whatever format it is held – paper, electronic, or oral. This statement applies to personal information that Blue Shield obtains, creates, and/or maintains about you and your covered dependents.

In the course of administering your Blue Shield coverage, we collect, use, and disclose information about you and your covered dependents, and we create records about you, your medical treatment, and the services we provide to you. The information in these records is called protected health information (“PHI”) and includes individually identifiable personal information such as your name, address, telephone number, and Social Security number, as well as your health information, such as healthcare diagnosis or claim information.

We obtain PHI about you and/or your covered dependents from you, at your direction, and/or with your permission. We also obtain your PHI from other sources as permitted by law, including, for example, from your healthcare provider, insurer, insurance support organization, health information exchange, health plan, or insurance agent. We use and disclose your PHI to administer your Blue Shield coverage and as otherwise permitted or required by law. In doing so, we may disclose your PHI to others including, for example, a healthcare provider, insurer, insurance support organization, health information exchange, health plan, or your insurance agent.

Blue Shield maintains a Notice of Privacy Practices (“Notice”) that describes your privacy rights, our obligations to protect your privacy, and how we use your PHI with and without your specific authorization. When we use or disclose your PHI, we are bound by the terms of the Notice, which applies to all records that we create, obtain, and/or maintain that contain your PHI. You will receive our Notice when you enroll for Blue Shield insurance coverage. You may also obtain a copy of our Notice by calling the customer service number on your Blue Shield member ID card or by visiting our website at: blueshieldca.com/bsca/about-blue-shield/privacy/confidentiality.sp.

California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage.

Agent/Broker AttestationAttestation of Agent/Broker assisting in the submission of this application: (1) to the best of my knowledge, the information on the application is complete and accurate; and (2) I have explained to the applicant, in easy-to-understand language, the risk to the applicant of providing inaccurate information and the applicant understood the explanation.

Signature of Agent/Broker_______________________________________________ Date _______________________

If an Agent/Broker willfully states as true any material fact he or she knows to be false, that person shall, in addition to any applicable penalties or remedies available under current law, be subject to a civil penalty of up to ten thousand dollars ($10,000). Any public prosecutor may bring a civil action to impose that civil penalty. These penalties shall be paid to the Insurance Fund.

C15390-H (1/18) Employee enrollment application (for 101+ employees) Page 4 of 4

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Blue Shield of California50 Beale Street, San Francisco, CA 94105 blueshieldca.com

Notice Informing Individuals about Nondiscrimination and Accessibility Requirements

Discrimination is against the law

Blue Shield of California complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Blue Shield of California does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

Blue Shield of California:

• Provides aids and services at no cost to people with disabilities to communicate effectively with us such as:

- Qualified sign language interpreters

- Written information in other formats (including large print, audio, accessible electronic formats and other formats)

• Provides language services at no cost to people whose primary language is not English such as:

- Qualified interpreters

- Information written in other languages

If you need these services, contact the Blue Shield of California Civil Rights Coordinator.

If you believe that Blue Shield of California has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with:

Blue Shield of California Civil Rights Coordinator P.O. Box 629007 El Dorado Hills, CA 95762-9007

Phone: (844) 831-4133 (TTY: 711) Fax: (916) 350-7405 Email: BlueShieldCivilRightsCoordinator@blueshieldca.com

You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, our Civil Rights Coordinator is available to help you.

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You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue SW. Room 509F, HHH Building Washington, DC 20201 (800) 368-1019; TTY: (800) 537-7697

Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.

IMPORTANT: Can you read this letter? If not, we can have somebody help you read it. You may also be able to get this letter written in your language. For help at no cost, please call right away at the Member/Customer Service telephone number on the back of your Blue Shield ID card, or (866) 346-7198.

IMPORTANTE: ¿Puede leer esta carta? Si no, podemos hacer que alguien le ayude a leerla. También puede recibir esta carta en su idioma. Para ayuda sin cargo, por favor llame inmediatamente al teléfono de Servicios al miembro/cliente que se encuentra al reverso de su tarjeta de identificación de Blue Shield o al (866) 346-7198. (Spanish)

重要通知：您能讀懂這封信嗎？如果不能，我們可以請人幫您閱讀。這封信也可以 用您所講的語言書寫

。如需免费幫助，請立即撥打登列在您的Blue Shield ID卡背面上的 會員/客戶服務部的電話，或者撥打

電話 (866) 346-7198。(Chinese)

QUAN TRỌNG: Quý vị có thể đọc lá thư này không? Nếu không, chúng tôi có thể nhờ người giúp quý vị đọc thư. Quý vị cũng có thể nhận lá thư này được viết bằng ngôn ngữ của quý vị. Để được hỗ trợ miễn phí, vui lòng gọi ngay đến Ban Dịch vụ Hội viên/Khách hàng theo số ở mặt sau thẻ ID Blue Shield của quý vị hoặc theo số (866) 346-7198. (Vietnamese)

MAHALAGA: Nababasa mo ba ang sulat na ito? Kung hindi, maari kaming kumuha ng isang tao upang matulungan ka upang mabasa ito. Maari ka ring makakuha ng sulat na ito na nakasulat sa iyong wika. Para sa libreng tulong, mangyaring tumawag kaagad sanumerong telepono ng Miyembro/Customer Service sa likod ng iyong Blue Shield ID kard, o (866) 346-7198. (Tagalog)

Baa’ ákohwiindzindoo7g7: D77 naaltsoos7sh y77niłta’go b77n7ghah? Doo b77n7ghahgóó é7, naaltsoos nich’8’ yiid0o[tah7g77 ła’ nihee hól=. D77 naaltsoos a[d0’ t’11 Din4 k’ehj7 1dooln77[ n7n7zingo b7ighah. Doo b22h 7l7n7g0 sh7k1’ adoowo[ n7n7zing0 nihich’8’ b44sh bee hod7ilnih d00 n1mboo 47 d77 Blue Shield bee n47ho’d7lzin7g7 bine’d44’ bik11’ 47 doodag0 47 (866) 346-7198 j8’ hod77lnih. (Navajo)

중요: 이 서신을 읽을 수 있으세요? 읽으실 수 경우, 도움을 드릴 수 있는 사람이 있습니다. 또한 다른

언어로 작성된 이 서신을 받으실 수도 있습니다. 무료로 도움을 받으시려면 Blue Shield ID 카드 뒷면의

회원/고객 서비스 전화번호 또는 (866) 346-7198로 지금 전환하세요. (Korean)

ԿԱՐԵՎՈՐ Է․ Կարողանում ե՞ք կարդալ այս նամակը։ Եթե ոչ, ապա մենք կօգնենք ձեզ։ Դուք պետք է նաև կարողանաք ստանալ այս նամակը ձեր լեզվով։ Ծառայությունն անվճար է։ Խնդրում ենք անմիջապես զանգահարել Հաճախորդների սպասարկման բաժնի հեռախոսահամարով, որը նշված է ձեր Blue Shield ID քարտի ետևի մասում, կամ (866) 346-7198 համարով։ (Armenian)

ВАЖНО: Не можете прочесть данное письмо? Мы поможем вам, если необходимо. Вы также можете получить это письмо написанное на вашем родном языке. Позвоните в Службу клиентской/членской поддержки прямо сейчас по телефону, указанному сзади идентификационной карты Blue Shield, или по телефону (866) 346-7198, и вам помогут совершенно бесплатно. (Russian)

重要：お客様は、この手紙を読むことができますか？ もし読むことができない場合、弊社が、お客様をサポートする人物を手配いたします。 また、お客様の母国語で書かれた手紙をお送りすることも可能です。 無料のサポートを希望される場合は、Blue Shield IDカードの裏面に記載されている会員/お客様サービスの電話番号、または、(866) 346-7198にお電話をおかけください。 (Japanese)

انید توتوانیم کسی را برای کمک بھ شما در اختیارتان قرار دھیم. حتی میتوانید این نامھ را بخوانید؟ اگر پاسختان منفی است، میآیا می مھم:نسخھ مکتوب این نامھ را بھ زبان خودتان دریافت کنید. برای دریافت کمک رایگان، لطفاً بدون فوت وقت از طریق شماره تلفنی کھ در پشت

) با خدمات اعضا/مشتری تماس بگیرید.866( 346-7198تان درج شده است و یا از طریق شماره تلفن Blue Shieldت شناسی کار(Persian)

ਮਹੱਤਵਪੂਰਨ: ਕੀ ਤੁਸ� ਇਸ ਪੱਤਰ ਨੰੂ ਪੜ� ਸਕਦੇ ਹੋ? ਜੇ ਨਹ� ਤ� ਇਸ ਨੰੂ ਪੜ�ਨ ਿਵਚ ਮਦਦ ਲਈ ਅਸ� ਿਕਸੇ ਿਵਅਕਤੀ ਦਾ ਪ�ਬੰਧ ਕਰ

ਸਕਦ ੇਹ�। ਤੁਸ� ਇਹ ਪੱਤਰ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵਚ ਿਲਿਖਆ ਹੋਇਆ ਵੀ ਪ�ਾਪਤ ਕਰ ਸਕਦੇ ਹੋ। ਮੁਫ਼ਤ ਿਵਚ ਮਦਦ ਪ�ਾਪਤ ਕਰਨ ਲਈ ਤਹੁਾਡ ੇ

Blue Shield ID ਕਾਰਡ ਦ ੇਿਪੱਛ ੇਿਦੱਤ ੇਮ�ਬਰ/ਕਸਟਮਰ ਸਰਿਵਸ ਟੈਲੀਫ਼ਨੋ ਨੰਬਰ ਤ,ੇ ਜ� (866) 346-7198 ਤੇ ਕਾੱਲ ਕਰੋ। (Punjabi)

្រប�រស�ំន់៖ េតើអ�ក�ចលិខិតេនះ �នែដរឬេទ? េបើមិន�ចេទ េយើង�ចឲ្យេគជួយអ�កក� �ង�រ�នលិ ខិតេនះ។ អ�កក៏�ចទទួល�នលិខិតេនះ���របស់អ�កផងែដរ។ ស្រ�ប់ជនួំយេ�យឥតគិតៃថ� សូមេ�ទូរស័ព��� មៗេ��ន់េលខទូរស័ព�េស�ស�ជិក/អតិថិជនែដល�នេ�េលើខ�ងប័ណ� ស�� ល់ Blue Shield របស់អ�ក ឬ�មរយៈេលខ (866) 346-7198។ (Khmer)

تستطیع قراءة ھذا الخطاب؟ أن لم تستطع قراءتھ، یمكننا إحضار شخص ما لیساعدك في قراءتھ. قد تحتاج أیضاً إلى الحصول على ھذا ھلالمھم :ب نالخطاب مكتوباً بلغتك. للحصول على المساعدة بدون تكلفة، یرجى االتصال اآلن على رقم ھاتف خدمة العمالء/أحد األعضاء المدون على الجا

(Arabic)).866( 346-7198أو على الرقم Blue Shieldبطاقة الھویة الخلفي من

TSEEM CEEB: Koj pos tuaj yeem nyeem tau tsab ntawv no? Yog hais tias nyeem tsis tau, peb tuaj yeem nrhiav ib tug neeg los pab nyeem nws rau koj. Tej zaum koj kuj yuav tau txais muab tsab ntawv no sau ua koj hom lus. Rau kev pab txhais dawb, thov hu kiag rau tus xov tooj Kev Pab Cuam Tub Koom Xeeb/Tub Lag Luam uas nyob rau sab nraum nrob qaum ntawm koj daim npav Blue Shield ID, los yog hu rau tus xov tooj (866) 346-7198. (Hmong)

สาํคญั: คณุอา่นจดหมายฉบบัน้ีไดห้รอืไม ่หากไมไ่ด ้โปรดขอคงามชว่ยจากผูอ้า่นได ้คุณอาจไดร้บัจดหมายฉบบัน้ีเป็นภาษาของคณุ หากตอ้งการความชว่ยเหลอืโดยไมม่คีา่ใชจ้า่ย โปรดตดิต่อฝา่ยบรกิารลูกคา้/สมาชกิทางเบอรโ์ทรศพัทใ์นบตัรประจาํตวั Blue Shield ของคุณ หรอืโทร (866) 346-7198 (Thai)

महत्वपणूर्: क्या आप इस पत्र को पढ़ सकत ेह�? य�द नह�ं, तो हम इसे पढ़ने म� आपक� मदद के �लए �कसी व्यिक्त का प्रबधं कर सकत ेह�। आप इस पत्र को अपनी भाषा म� भी प्राप्त कर सकत ेह�। �न:शलु्क मदद प्राप्त करने के �लए अपने Blue Shield ID काडर् के पीछे �दए गये म�बर/कस्टमर स�वर्स टेल�फोन नबंर, या (866) 346-7198 पर कॉल कर�। (Hindi)

blueshieldca.com

blueshieldca.com

Notice of the Availability of Language Assistance ServicesBlue Shield of California Life & Health Insurance Company

Reason for Application: OffLoss of coverage date: other qualifying event type: Re-hire date: Date above event occurred: Specialty Benefits - Dental PPO: OffSpecialty Benefits - Dental PPO plan name: Medical Benefits - Access+ HMO: OffMedical Benefits - Access+ HMO SaveNet: OffMedical Benefits - Added Advantage POS: OffMedical Benefits - Trio ACO HMO: OffMedical Benefits - Active Choice: OffMedical Benefits - Blue Shield 65 Plus: OffAccess+ HMO plan name: Medical Benefits with ABHP - Access+ HMO - HRA: OffMedical Benefits with ABHP - Access+ HMO - HIA: OffMedical Benefits with ABHP - Access+ HMO - FSA: OffMedical Benefits with ABHP - Active Choice - HRA: OffMedical Benefits with ABHP - Active Choice - FSA: OffSpecialty Benefits - Other: OffMedical Benefits - Local Access+ HMO: OffSpecialty Benefits - Dental HMO plan name: Access+ HMO SaveNet plan name: Specialty Benefits - Vision plan name: Specialty Benefits - Vision: OffLocal Access+ HMO plan name: Specialty Benefits - Other plan name: Added Advantage POS plan name: Medical Benefits with ABHP - Local Access+ HMO - HRA: OffMedical Benefits with ABHP - Local Access+ HMO - HIA: OffMedical Benefits with ABHP - Local Access+ HMO - FSA: OffSpecialty Benefits - Dental HMO: OffTrio ACO HMO plan name: Medical Benefits with ABHP - Full PPO - HRA: OffMedical Benefits with ABHP - Full PPO - HIA: OffMedical Benefits with ABHP - Full PPO - FSA: OffMedical Benefits - Full PPO: OffMedical Benefits with ABHP - Full PPO - Savings - HSA: OffActive Choice plan name: Medical Benefits with ABHP - Full PPO Savings- HIA: OffMedical Benefits with ABHP - Full PPO Savings - LPFSA: OffFull PPO plan name: Medical Benefits with ABHP - Full PPO Savings - FSA: OffMedical Benefits with ABHP - Full PPO ASO - HRA: OffMedical Benefits with ABHP - Full PPO ASO - HIA: OffMedical Benefits - Full PPO ASO/Full PPO ASO Savings: OffMedical Benefits with ABHP - Full PPO Savings - HRA: OffFull PPO ASO/Full PPO ASO Savings plan name: Medical Benefits with ABHP - Full PPO ASO Savings - HRA: OffMedical Benefits with ABHP - Full PPO ASO - FSA: OffMedical Benefits with ABHP - Full PPO ASO Savings- HIA: OffMedical Benefits with ABHP - Full PPO ASO Savings - LPFSA: OffMedical Benefits with ABHP - Full PPO ASO - Savings - HSA: OffMedical Benefits with ABHP - Full PPO ASO Savings - FSA: OffInternal use only - Department code: Internal use only - Group ID: Internal use only - Subgroup ID: Internal use only - Effective date: Medical Benefits with ABHP - Active Choice - HIA: OffInternal use only - Class ID: Employee Social Security number: Employer group name: Employee last name: Employee first name: Employee middle initial: Employee status: OffEmployee date of hire: Job title/classification: Employee home address: Employee mailing address: Employee home phone number: Employee email address: Contact preference: OffEmployee birth date: Gender: OffMarital status: OffLanguage preference: OffOther language: Are you enrolling your spouse/domestic partner and/or child dependents?: OffName of primary care physician (PCP): Primary care physician (PCP) provider number: Primary care physician (PCP) existing patient?: OffIPA/MG name: IPA/MG number: Dental provider existing patient?: OffName of dental provider: Dental provider number: Dependent’s address, if different from employee – please indicate which dependent(s) this applies to: First dependent relationship: OffFirst dependent gender: OffSecond dependent gender: OffFirst dependent's doctor's first name: First dependent first name: First dependent middle initial: First dependent's doctor's last name: First dependent last name: First dependent's dental provider's first name: First dependent Social Security Number: Enroll First dependent in Dental: OffFirst dependent's dental provider's last name: Enroll First dependent in Medical: OffFirst dependent's doctor's provider number: First dependent's doctor's IPA/MG name: First dependent's dental provider's number: Enroll First dependent in Vision: OffFirst dependent's doctor's IPA/MG number: First dependent date of birth: First dependent's doctor's existing patient: OffFirst dependent's dental provider's existing patient: OffSecond dependent first name: Second dependent's doctor's first name: Second dependent middle initial: Second dependent's dental provider's first name: Second dependent's doctor's last name: Second dependent's dental provider's last name: Second dependent last name: Second dependent's doctor's provider number: Second dependent Social Security Number: Second dependent's doctor's IPA/MG number: Second dependent disabled?: OffSecond dependent date of birth: Enroll Second dependent in Medical: OffSecond dependent's dental provider's number: Enroll Second dependent in Dental: OffEnroll Second dependent in Vision: OffSecond dependent's doctor's existing patient: OffSecond dependent's dental provider's existing patient: OffSecond dependent's doctor's provider name: Third dependent gender: OffFourth dependent gender: OffThird dependent first name: Third dependent middle initial: Third dependent last name: Third dependent Social Security Number: Third dependent date of birth: Third dependent disabled?: OffEnroll Third dependent in Medical: OffThird dependent's doctor's first name: Third dependent's dental provider's first name: Third dependent's doctor's last name: Third dependent's dental provider's last name: Third dependent's doctor's provider number: Third dependent's dental provider's number: Enroll Third dependent in Dental: OffEnroll Third dependent in Vision: OffThird dependent's doctor's IPA/MG number: Third dependent's doctor's existing patient: OffThird dependent's dental provider's existing patient: OffFourth dependent's doctor's first name: Fourth dependent first name: Fourth dependent middle initial: Fourth dependent's dental provider's first name: Fourth dependent's doctor's last name: Fourth dependent's dental provider's last name: Fourth dependent last name: Fourth dependent's doctor's provider number: Fourth dependent Social Security Number: Fourth dependent's dental provider's number: Fourth dependent's doctor's IPA/MG number: Enroll Fourth dependent in Dental: OffEnroll Fourth dependent in Vision: OffFourth dependent date of birth: Fourth dependent disabled?: OffEnroll Fourth dependent in Medical: OffFourth dependent's doctor's existing patient: OffFourth dependent's dental provider's existing patient: OffThird dependent's doctor's provider name: Fourth dependent's doctor's provider name: Are you or any of your dependents currently covered by Medicare?: OffType of Medicare coverage - Part A: OffType of Medicare coverage - Part B: OffPart A effective date: Part B effective date: Is Medicare eligibility due to End Stage Renal Disease (ESRD)?: OffFirst date of dialysis treatment: Type of dialysis treatment: OffDate of kidney transplant: Authorization signature date: Authorization print name: Authorization signature date 2: Authorization print name 2: Agent/Broker Attestation signature date: Medical Benefits - Full PPO Savings: OffFull PPO Savings plan name: Medical Benefits - Tandem PPO: OffMedical Benefits - Tandem PPO Savings: OffTandem PPO plan name: Tandem PPO Savings plan name: