cbg|CONFIDENT MetLife Dental Broker Kit

cbg|CONFIDENT

08/11

M E T L I FE N EW G R OUP SUB MIS S I ON P R O CESS

Submission Deadline: New group information must be postmarked no later than the 30th of the month to be effective for the first of the following month.

NEW BUSINESS CHECK LIST

Please confirm that the following is submitted with all new cases.

Completed Employer Application

Completed Verification of Eligibility

Completed Employee Enrollments and each employee received the privacy notice.

First Month’s Premium (Made payable to: Employer Plan Services, Inc.)

Copy of Proposal and signature by the rates accepting the rates.

Producer Licensing Forms (if not previously contracted)

SUBMIT ALL ORIGINAL FORMS TO

cbg | CONFIDENT 5006 Lyndale Avenue South

Minneapolis, MN 55419 (612) 827-0855 or toll free (888) 327-8880

info@capital-benefits.com

cbg CONFIDENTDental Plans

cbg o�ers a full line of CONFIDENT ancillary bene�t plans.

CONFIDENT o�ers employer paid and contributory plans starting at 2 enrolled employees. Voluntary plans are available for groups with 5 enrolled employees or 35% participation which ever is greater.

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With CONFIDENT & MetLIfe dental you can customize your clients’ plan based on their needs and budget, select from a variety of annual maximums, U&C schedules, benefit placement options and participation levels.

Unmatched customer service from a name you can trust making us the clear choice for discerning employers.

Select from a menu of ancillary programs, including life, short-term disability, long-term disability and vision insurance plans.

cbg & MetLife Offering Your Customers Dental Programs With Greater Value

CONFIDENT programs are designed and developed by Capital Bene�ts Group, Minneapolis, MN. CONFIDENT is a registered trademark of Capital Bene�ts Group, all rights reserved. Administration for CONFIDENT is provided by Employer Plan Services, Inc, Houston, TX. . For more information contact cbg at 888.327.8880 or www.capital-bene�ts.com. For Agent use only. Not for General Distribution.

Preventive and Diagnostic Services Clinical oral exams (one per six consecutive month period) Cleaning (one per six consecutive month period) X-Ray: bitewings (one time in twelve months)

100%

Service & Description

Per person/per family (calendar year)

Deductible (waived for Preventive and Diagnostic Services) $50/$150

A customized CONFIDENT plan will meet the needs of employers and employees. The following options may be available based on group size and participation: $1250, $1500, $1750 or $2000 annual maximum based on group size. Child Orthodontia $1000 or $1500 lifetime maximum. 10 enrolled employee minimum. Endodontics, Periodontics and Oral Surgery can be payable in basic. 80%, 90% and 99% Usual and Customary Multiple Deductible options: $0, $25 or $50 MAC and DHMO options available in certain states

Calendar Year Plan Maximum Per Person (for non orthodontic services) $1,000

www.con�dentbene�ts.com | Tel. 888-327-8880

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Coverage LevelIn-Network/ Out-of-Network

Basic Services: No Waiting Periods Restorations and �llings Sealants (children under age 16) Simple Extractions

Major Services: No Waiting Periods Endodontics Periodontics Oral Surgery Inlays and crowns Implants Bridges

80%

50%

MetLife PDP Plus Network has 276,134 access points nationally

APP-GP99 NW/F

Metropolitan Life Insurance Company 200 Park Avenue, New York, New York 10166

APPLICATION FOR GROUP INSURANCE

The applicant named below is applying for a Group Policy to provide insurance for the persons specified below. APPLICANT DATA 1. Full legal name of Applicant: (the “Policyholder”)

2. Address: City State Zip POLICY EFFECTIVE DATE The Group Policy’s effective date will be , subject to MetLife’s acceptance of this application and the Applicant’s payment of the Premium due on or before such date. POLICY SITUS The Group Policy will be issued for delivery in and governed by the laws of

COVERAGE DATA Employees / Members Dependents Basic Life Basic Life with AD&D Supplemental Life Supplemental Life with AD&D Dental Short Term Disability Long Term Disability Vision PREMIUM DATA Premiums will be paid: monthly quarterly annually other:

Attached is an advance payment of: $ . AGREEMENT The Applicant signing below agrees to accept the terms and provisions of the Group Policy, including its Exhibits, amendments and endorsements, if any.

Fraud Warning. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

(Signature of Applicant’s Authorized Representative) (Print Name and Title of Authorized Representative) Signed at: Date: (City) (State)

(Signature of Witness) (Print Name of Witness) (Signature of Licensed MetLife Agent or Resident (Agent’s State License No.) (Print Name of Agent) Agent as required by law)

CUSTOMER INFORMATION

Legal Name of Company:

Legal Address of Company (No PO Boxes):

Address Line 2:

City, State, Zip:

Employer Tax Identification Number (TIN):

SIC Code used to Rate Group: Year Company Founded:

Effective Date: Broker Due Date: Next Business Day

Number of eligible employees:

Coverage(s) sold: n Basic Life n PPO Dental n Vision n ER Sponsored Short Term Disability

n Supplemental Life n DHMO n Long Term Disability n Voluntary Short Term Disability

Does this group have existing coverage with MetLife? If yes, please include the group #:

BROKER INFORMATION

Broker First and Last Name:

Social Security #:

Corporation Name:

Federal Tax ID:

Resident State:

Broker Address 1:

Broker Address 2:

Broker City, State, Zip:

Broker Contact Name: Phone: Email:

Is Broker Appointed with MetLife? n Yes n No If no or unsure, please contact your assigned Client Acquisition Associate

Commissions Paid to: n Writing Producer n Brokerage

GA/TPA Name :

GA/TPA Writing Producer First & Last Name:

GA/TPA Local Sales Office Address:

GA/TPA Contact Name: Email:

METLIFE SALES INFORMATION: TO BE COMPLETED BY METLIFE, INTERNAL USE ONLY

MetLife Sales Office:

MetLife Sales Rep:

MetLife Contact:

Metlife CAA Email:

PRIMARY CONTACT/BENEFIT ADMINISTRATOR INFORMATION

Contact First and Last Name:

Billing Address Line 1 (if different than above):

Billing Address Address Line 2:

City, State, Zip:

Contact Email:

Contact Phone/Fax:

Should this contact have access to: MetLink® n Yes n No

Do you wish for your GA/Broker to have MetLink access to your account? n Yes n No

CUSTOMER EXECUTIVE CONTACT INFORMATION — n Same as Above

Contact First and Last Name:

Contact Email:

Contact Phone/Fax:

Should this contact have access to MetLink®: n Yes n No* MetLink® – Our Online administration system designed to make benefits administration easier. MetLink provides convenient, real-time access to MetLife’s systems – enabling you to efficiently

add or modify employees employee information and look up dental or disability claim status.

ELIGIBILITY INFORMATION

Class Description: All Active Full Time Employees Number of hours worked: 30 hours

Waiting Period Coverage eff date

Days

Months

n Date Eligible

n 1st of Month Following Waiting Period

Do you want the above waiting period to be waived for new hires and make them effective on the policy effective date? n Yes n No

If you have additional classes or if class description or number of hours worked differs from above, please provide the eligibility information mentioned above for each class in the space provided below.

Domestic Partners: If your state does not require domestic partner and you would like it removed, please check here. n Please Remove Domestic Partner

PREMIUM CONTRIBUTIONS

Employer Contribution Percentage — If the employer pays 100% of the premium, all eligible employees must participate.

emPloyer’s Contribution on behalf of:

basiC life/ ad&d

suPPlemental life/ad&d

dental PPo

dental dhmo vision ltd

voluntary std

er sPonsored std

Employee % % % % % %n Pre Tax n Post Tax

%n Pre Tax n Post Tax

%n Pre Tax n Post Tax

Dependent % % % % % n/a n/a n/a

EARNINGS DEFINITION

n Basic Earnings Only n + Commissions n + Bonus

Average over n 12 Months n 24 Months n 36 Months

Section 125: Is your policy covered under Section 125? n Yes n No

ERISA INFORMATION

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MetLife provides as a standard service for ERISA plans a document entitled “ERISA Information” that, together with your insurance certificate, can be used as your Summary Plan Description. This includes a grant of discretion to MetLife, as claims administrator. If you do not want MetLife to provide this “ERISA Infor-mation” please notify your broker so the appropriate modifications can be completed.

Special Case Notes (FOR METLIFE INTERNAL USE ONLY):

LIFE, SHORT TERM DISABILITY OR LONG TERM DISABILITY COVERAGES:

Are there any significant health risks within this customer? n Yes n No

If “Yes”, please provide details (do not include individual names):

Employees Not Actively At Work – Please list any current employees not actively working (excluding employees on vacation) as of the effective date. These employees must be disclosed and are not eligible for coverage until they return to work.

Name: Reason:

Name: Reason:

Name: Reason:

DISABILITY ONLY

n MetLife will issue W2’s for LTD and STD n Customer will issue W2’s for LTD and STD

The employer will receive an Employer W2 report annually if MetLife issues the W2’s.

Note: The benefits must be taxable or MetLife’s system will not produce a W2

If you are using a payroll vendor, have you discussed with your Payroll Vendor who should be issuing W2’s for taxable disability benefit payments (Third Party Sick Pay)? If you have not discussed this matter and obtained an agreement with your Payroll Vendor you may experience W2 and tax reporting issues at the end of the tax year.

Are there any individuals being covered that are FICA exempt or partially FICA exempt? n Yes n No

If you have both FICA exempt and non FICA exempt employees additional class structure may be required for your FICA exempt employees. Please identify all FICA exempt employees on your enrollment listing (census) and their exemption status (Social Security and/or Medicare)

Please check all that apply: n Social Security Exempt n Medicare Exempt n Social Security & Medicare Exempt

Please explain why your employees are exempt from FICA (Social Security and/or Medicare):

n Municipality n Schools n Religious Organization n Other:

Do the FICA exemptions described above apply to all covered employees? n Yes n No

AUTHORIZATIONS

MetLife will deliver the group insurance policy and certificates to the company via e-mail as Adobe pdf documents and confirms that it is able to save them as electronic records and print them (if requested) for distribution to individuals who become covered under the group insurance policy.

HIPAA Information (Dental Only):

n I am an authorized representative of the MetLife customer named above. By checking this box, I understand and confirm that no access will be given to employee’s Protected Health Information (PHI).

This section is to be completed by the individual authorized by the company to sign the Application for Group Insurance in order to confirm that the company has requested or undertaken with respect to the implementation of MetLife insurance and/or service program(s). Please read carefully and complete by checking all boxes that apply.

n By checking this box and signing below, I certify that I received a copy of the Intermediary Compensation Notice (included below)

n By checking this box and signing below, I certify that the Gramm-Leach-Bliley Privacy Notice (included with their document) has been distributed to all affected employees.

Signature of Executive Contact or Benefit Administrator Date

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7.

8.

cbg|CONFIDENT

VERIFICATION OF ELIGIBILITY

Participation Requirements are a condition of coverage. These requirements vary depending on plan selected. Please complete this form to verify eligibility. Statements made below may be used to contest a claim of any policy issued.

1. Employer Contribution EE Dep

2. Total Number of Employees on Payroll

3. Total Number of Employees working 1-29 hours per week (include temporary and/or seasonal employees)

4. Total number of employees in waiting period

5. Number of full-time eligible employees (subtract numbers 3 and 4 from number 2)

For employer paid group coverage or for employee paid voluntary plans, participation will be calculated from using numbers 7 and 8.

Total Number of Employees who are covered under their spouses plan or have other

coverage. (an enrollment form with a signed waiver must be submitted)

Number of eligible employees (subtract numbers 6 from number 5)

Total number of full-time employees enrolled in group dental plan

9. Eligibility waiting period for new employees days

AGREEMENT AND SIGNATURE It is understood and agreed as follows: 1. No coverage is effective until approved. 2. Insurance will be effective with regard to those individuals listed in the Eligibility Section of the Application, upon approval of the

completed, signed application and the first months premium . 3. No agent has the authority to waive any of the Company’s rights or requirements, or to make or alter any contract or policy.

Dated at this day of .

Signature

Type or Print Name Title

Company Name

5006 Lyndale Avenue South | Minneapolis, MN 55419 | 888.327.8880 f. 612.825.8392 | www.confidentbenefis.com 07182011

cbg|CONFIDENT

Send Completed Forms to: cbg|CONFIDENT | 5006 Lyndale Ave. So. | Minneapolis, MN 55419 | t. 888.327.8880 f. 612.825.8392Adminstrated by: EPSi | PO Box 2727 | Houston, TX 77252 | T. 800.207.9224 | F. 713.369.0703

A. Employee Information (Complete for ALL Enrollments)Employer Name/Company Name (Please Print) Division Group ID County State

Last Name First Name MI Social Security Number

Address City State Zip Date of Birth

Male Marital Status*: Married Divorced Spouse's* Date of Birth Home Phone Work Phone Female Single WidowedCompleted By EmployerEffective Date: Date of Full-Time Employment: Occupation: Employee ID:

Earnings: $________________ Hourly Weekly Monthly Yearly Hours Worked Per Week:

Payroll Mode: Weekly Other:_____________PRODUCT SELECTION (Complete for ALL Enrollments)CONFIDENT Dental Underwritten by Metropolitan Life Insurance CompanyType of Coverage Yes/No Amount of Coverage PremiumDental Yes No Employee

Employee/Spouse Employee/Child Family

C. Dependent and Other Insurance Information Last Name First Name MI Sex Birth Date

SpouseChild(ren)

E. Signature (Complete for ALL Enrollments)Signature Section:I understand that by selecting "no", if I desire to participate in the Program at some future date, my coverage or my dependents' coverage willnot be effective until after Evidence of Insurability is submitted and approved. I understand if a physical examination or further medical information is required, it will be at my own expense.

I hereby apply for group insurance, for which I am eligible or may become eligible. If contributions are required, I authorize my employer todeduct premiums from my salary. I reserve the right to revoke this deduction at any time on written notice.

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

*Spouse or Marriage, as defined by governing state law or as otherwise agreed upon between the policyholder and the insurer.

___________________________________________________ _________________Employee Signature Date Signed

Waiving Coverage: I have dental coverage through my spouse I don't want coverage

New Enrollment

MetLife Employee Enrollment Form

Bi-Weekly Semi-Monthly Monthly

cbg|CONFIDENT

Send Completed Forms to: cbg|CONFIDENT | 5006 Lyndale Ave. So. | Minneapolis, MN 55419 | t. 888.327.8880 f. 612.825.8392Adminstrated by: EPSi | PO Box 2727 | Houston, TX 77252 | T. 800.207.9224 | F. 713.369.0703

FRAUD WARNINGSDistrict of Columbia, Louisiana, Maryland, and Rhode Island

Florida

Kansas

Kentucky

Massachusetts, North Carolina and Oregon

New Jersey

Oklahoma

Puerto Rico

Tennessee and Washington

Virginia

Vermont

For Maine and All other states  Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement ofclaim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material theretocommits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

FORM CBGEE6.11

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, any information concerning any fact material thereto, commits a fraudulent insurance act which is a crime.

I understand that any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, any information concerning any fact material thereto, commits a fraudulent insurance act which may be a crime and may subject such person to criminal and civil penalties.

I understand that any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

I understand that any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law.

I understand that any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, any information concerning any fact material thereto, may be committing a fraudulent insurance act which may be a crime subject to criminal and civil penalties.

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

I understand that 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.

Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Any person who knowingly and with the intention to defraud includes false information in an application for insurance or file, assist or abet in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years.

It is a crime to knowingly present false, incomplete or misleading information to an insurance company for the purpose of defrauding thecompany.  Penalties include imprisonment, fines and denial of insurance benefits.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto may be guilty of insurance fraud as determined by a court of law.

CPN–Inst–Initial Enr/SOH -2009v2

Our Privacy Notice We know that you buy our products and services because you trust us. This notice explains how we protect your privacy and treat your personal information. It applies to current and former customers. “Personal information” as used here means anything we know about you personally.

Plan Sponsors and Group Insurance Contract Holders

This privacy notice is for individuals who apply for or obtain our products and services under an employee benefit plan, or group insurance or annuity contract. In this notice, “you” refers to these individuals.

Protecting Your Information

We take important steps to protect your personal information. We treat it as confidential. We tell our employees to take care in handling it. We limit access to those who need it to perform their jobs. Our outside service providers must also protect it, and use it only to meet our business needs. We also take steps to protect our systems from unauthorized access. We comply with all laws that apply to us.

Collecting Your Information

We typically collect your name, address, age, and other relevant information. We may also collect information about any business you have with us, our affiliates, or other companies. Our affiliates include life, car, and home insurers. They also include a bank, a legal plans company, and securities broker-dealers. In the future, we may also have affiliates in other businesses.

How We Get Your Information

We get your personal information mostly from you. We may also use outside sources to help ensure our records are correct and complete. These sources may include consumer reporting agencies, employers, other financial institutions, adult relatives, and others. These sources may give us reports or share what they know with others. We don’t control the accuracy of information outside sources give us. If you want to make any changes to information we receive from others about you, you must contact those sources.

We may ask for medical information. The Authorization that you sign when you request insurance permits these sources to tell us about you. We may also, at our expense:

• Ask for a medical exam • Ask for blood and urine tests • Ask health care providers to give us health data, including information about alcohol or drug abuse We may also ask a consumer reporting agency for a “consumer report” about you (or anyone else to be insured). Consumer reports may tell us about a lot of things, including information about: • Reputation • Driving record • Finances • Work and work history • Hobbies and dangerous activities The information may be kept by the consumer reporting agency and later given to others as permitted by law. The agency will give you a copy of the report it provides to us, if you ask the agency and can provide adequate identification. If you write to us and we have asked for a consumer report about you, we will tell you so and give you the name, address and phone number of the consumer reporting agency. Another source of information is MIB Group, Inc. (“MIB”). It is a non-profit association of life insurance companies. We and our reinsurers may give MIB health or other information about you. If you apply for life or health coverage from another member of MIB, or claim benefits from another member company, MIB will give that company any information that it has about you. If you contact MIB, it will tell you what it knows about you. You have the right to ask MIB to correct its information about you. You may do so by writing to MIB, Inc., 50 Braintree Hill, Suite 400, Braintree, MA 02184-8734, by calling MIB at (866) 692-6901 (TTY (866) 346-3642 for the hearing impaired), or by contacting MIB at www.mib.com. Using Your Information

We collect your personal information to help us decide if you’re eligible for our products or services. We may also need it to verify identities to help deter fraud, money laundering, or other crimes. How we use this information depends on

CPN–Inst–Initial Enr/SOH -2009v2

2

what products and services you have or want from us. It also depends on what laws apply to those products and services. For example, we may also use your information to:

• administer your products and services • process claims and other transactions • perform business research • confirm or correct your information • market new products to you • help us run our business • comply with applicable laws

Sharing Your Information With Others

We may share your personal information with others with your consent, by agreement, or as permitted or required by law. For example, we may share your information with businesses hired to carry out services for us. We may also share it with our affiliated or unaffiliated business partners through joint marketing agreements. In those situations, we share your information to jointly offer you products and services or have others offer you products and services we endorse or sponsor. Before sharing your information with any affiliate or joint marketing partner for their own marketing purposes, however, we will first notify you and give you an opportunity to opt out.

Other reasons we may share your information include:

• doing what a court, law enforcement, or government agency requires us to do (for example, complying with search warrants or subpoenas)

• telling another company what we know about you if we are selling or merging any part of our business • giving information to a governmental agency so it can decide if you are eligible for public benefits • giving your information to someone with a legal interest in your assets (for example, a creditor with a lien

on your account) • giving your information to your health care provider • having a peer review organization evaluate your information, if you have health coverage with us • those listed in our “Using Your Information” section above HIPAA

We will not share your health information with any other company – even one of our affiliates – for their own marketing purposes. If you have dental, long-term care, or medical insurance from us, the Health Insurance Portability and Accountability Act (“HIPAA”) may further limit how we may use and share your information.

Accessing and Correcting Your Information

You may ask us for a copy of the personal information we have about you. Generally, we will provide it as long as it is reasonably retrievable and within our control. You must make your request in writing listing the account or policy numbers with the information you want to access. For legal reasons, we may not show you anything we learned as part of a claim or lawsuit, unless required by law.

If you tell us that what we know about you is incorrect, we will review it. If we agree, we will update our records. Otherwise, you may dispute our findings in writing, and we will include your statement whenever we give your disputed information to anyone outside MetLife.

Questions

We want you to understand how we protect your privacy. If you have any questions about this notice, please contact us. When you write, include your name, address, and policy or account number.

Send privacy questions to:

MetLife Privacy Office, P. O. Box 489, Warwick, RI 02887-9954 privacy@metlife.com

We may revise this privacy notice. If we make any material changes, we will notify you as required by law. We provide this privacy notice to you on behalf of these MetLife companies:

Metropolitan Life Insurance Company MetLife Insurance Company of Connecticut General American Life Insurance Company SafeGuard Health Plans, Inc. SafeHealth Life Insurance Company