Group Master Application Level Funded ProductBANKING INFORMATION (for ACH) ... contact your Sales Representative before signing this application. ... All material terms of coverage

University of Utah Health Insurance Plans PO Box 45180

Salt Lake City, UT 84145 [email protected]

LF Group Application

Group Master Application – Level Funded Product

Please complete and submit this application to our office no later than 15 days prior to the effective date or there may be

delays to the processing and activation of your group. If additional space is needed please attach a separate sheet of paper.

Requested Effective Date _______________________

Section 1 – Group Information Group’s Legal Name Company Structure

Sole Proprietorship

Partnership

Corporation

Other Doing Business As (DBA) Federal Tax ID Number (EIN) Name to be used by UUHP

Legal

DBA

Physical Business Address Required (No PO Box or PMB) If subsidiaries/affiliates are to be covered please provide a list of all locations.

Mailing Address (if different from Physical Business Address)

Phone Number Fax Number

PRIMARY GROUP CONTACT Name (First, MI, Last) Title

Phone Number E-mail Address

GROUP ADMINISTRATOR (if different than primary contact) Name (First, MI, Last) Title


BILLING Billing Contact Name (First, MI, Last) Title


AGENT INFORMATION Agency Name Agent Name


Phone Number

Section 2 - Eligibility

PROBATIONARY PERIOD Class 1 – First of the month following Date of Hire 30 Days 60 Days 90 Days Benefits terminate at the end of the month

Class 2 – First of the month following Date of Hire 30 Days 60 Days 90 Days Benefits terminate at the end of the month

Class 3 – First of the month following Date of Hire 30 Days 60 Days 90 Days Benefits terminate at the end of the month

Will the plan cover domestic partners? Yes No

Will the plan cover retirees? Yes No




Section 3 – Plan Details

PLAN SELECTION - Please check all plan designs being offered Healthy Premier Network (Statewide)

$500 80/20 Premier PPO




$1500 80/20 Premier QHDHP PPO

$2700 80/20 Embedded Premier QHDHP PPO



Healthy Preferred Network (Wasatch Front)

$500 80/20 Preferred EPO




$1500 80/20 Preferred QHDHP EPO

$2700 80/20 Embedded Preferred QHDHP EPO



Administrative Details- Will the group be using Health Equity? Yes No *This will be a $2.95 per account, per month, charged by HE directly to the group.

Section 4 – Billing BANKING INFORMATION (for ACH) – Premiums will be drafter the 1st of each month

Bank Name:

Routing Number:

Account Number:

Contact (if different than billing contact) Contact Name (First, MI, Last) Title


Section 5 – Acknowledgements and Certifications If you have any questions about the benefits and services that are covered, provided, limited or excluded under the group coverage(s) to which this application applies, please contact your Sales Representative before signing this application. Note: The Company as used here means the group applying for coverage as indicated in Section 1 of this application. I certify that I am an officer or employee of the Company, that I am duly authorized to execute this application on behalf of the Company, and that the Company:

a) Applies for the group coverage(s) selected in the signed rate and benefits page(s) which form a part of the group contract(s) issued by University

of Utah Health Insurance Plans.

b) Authorizes any person or other entity to release to University of Utah health Insurance Plans any information requested by University of Utah

Health Insurance Plans in connection with this application's processing.

c) Acknowledges, where permitted by law, that University of Utah Health Insurance Plans may choose not to approve this application and any

premium deposit will be returned if the application for group coverage(s) is not approved.

d) Acknowledges that coverage is not in effect until University of Utah Health Insurance Plans accepts this application, establishes an effective

date of coverage and issues the group contract(s) to the Company.

e) Acknowledges that, if it is approved by University of Utah Health Insurance Plans, this application will form a part of the group contract(s)

issued by University of Utah Health Insurance Plans and agrees that the Company will be bound by the terms and the conditions of entire

group contract(s).

f) Acknowledges that eligibility standards (e.g., waiting period, minimum hours, etc.) must be established at the time of initial application, may

be changed only at contract renewal, and must be adhered to for all employees and dependents.

g) Acknowledges that it has selected the group coverage(s) to be offered to its employees, that its selection of this group coverage(s) was based

upon written information provided by University of Utah Health Insurance Plans, and that no broker, agent, or consultant was or is authorized

to modify the terms of the offer or to agree to changes. All material terms of coverage are set forth in the group contract(s), of which this

application, if accepted, is but one part.

h) Agrees to make payroll and other records directly related to employee participation levels or to employees' coverage, premiums, or

contributions under the group contract(s) available to University of Utah Health Insurance Plans for inspection. This provision shall survive the

termination of the group contract(s). Upon renewal or anytime throughout the contract period, the Company agrees to provide University of

Utah Health Insurance Plans, upon its request verifications of employee participation levels.

i) Agrees that, except with regard to a statutory continuation of coverage or unless the change is approved in writing by an authorized

representative of University of Utah Health Insurance Plans, at no time shall any employee be permitted or required to make contributions for

coverage at a rate higher than the employee contribution rate represented herein.

j) Agrees the group contract(s) will determine the contractual provisions, including procedures, exclusions, and limitations, relating to the

coverage and will govern in the event of conflict with any benefits comparison, summary, or other description of the coverage.




k) Agrees to deliver, or otherwise make available to enrollees, all University of Utah Health Insurance Plans paper or online member documents

and other coverage- related materials upon request by University of Utah Health Insurance Plans.

l) Agrees to make all coverage options available to all eligible employees and dependents who satisfy eligibility requirements.

m) Acknowledges that benefits may be added or deleted only at the time of initial application, at contract renewal, when required by law, or as

mutually agreed between the Company and University of Utah Health Insurance Plans in accordance with the group contract(s).

n) Acknowledges that University of Utah Health Insurance Plans must be notified (in the manner described in the group contract(s)) when there

is a change to Company information (e.g., name, address, phone number, contact person, ownership status, etc).

o) Acknowledges that contracting physicians, hospitals, and other health care providers are independent contractors and are neither agents nor

employees of University of Utah Health Insurance Plans, that University of Utah Health Insurance Plans does not provide health care services,

and that University of Utah Health Insurance Plans cannot guarantee any results or outcomes of care. University of Utah Health Insurance Plans

is responsible for the quality of health care you receive only as provided by law.

p) Certifies under penalty of perjury that all statements made and information provided in this application are accurate and complete to the best

of its knowledge or belief and acknowledges that University of Utah Health Insurance Plans will rely in part on the information in this application

as the basis for University of Utah Health Insurance Plans' decision on whether to approve this application and issue any group contract(s). For

the protection of all of University of Utah Health Insurance Plans' members, fraud or misrepresentation of material fact by the Company for

the purposes of defrauding University of Utah Health Insurance Plans may result in University of Utah Health Insurance Plans taking any action

allowed by law or contract, including termination or rescission of coverage, denial of benefits, and/or pursuit of criminal charges and penalties.

In addition, University of Utah Health Insurance Plans will have the right to collect any claims payments or other damages. If University of Utah

Health Insurance Plans continues a group contract with the Company after untrue, incorrect, or incomplete information is found to have been

provided, and if as a result of correcting false information the Company no longer qualifies for the rate quoted, I understand that University of

Utah Health Insurance Plans will have the right to adjust the rates to the appropriate level retroactive to the date the misrepresentation

occurred, and the Company will be required to pay the rate adjustment within 30 days of the date of notice by University of Utah Health

Insurance Plans.

q) Agrees that any controversy or claim between the Company and University of Utah Health Insurance Plans arising out of or relating to the

group contract(s), or the breach thereof, whether involving a claim in tort, contract, or otherwise, shall be subject to final resolution through

binding arbitration. The Company and University of Utah Health Insurance Plans agree that the arbitrator's award shall be binding, may include

an apportionment of attorney fees and other fees and costs, and may be enforced in any court with the requisite jurisdiction. Any such

arbitration shall be conducted in accordance with the Commercial Arbitration Rules of the American Arbitration Association and in Salt Lake

County, Utah), unless mutually agreed otherwise by the parties. If any enrollee or former enrollee (or person claiming to be an enrollee or

former enrollee) makes any claim or brings any action or proceeding arising out of or relating to the group contract(s) to which University of

Utah Health Insurance Plans or the Company becomes a party, University of Utah Health Insurance Plans and the Company agree to cooperate

in the defense of such claim, action, or proceeding and to resolve any controversy or claim between University of Utah health Insurance Plans

and the Company through arbitration under this paragraph only after the resolution of the enrollee's (or alleged enrollee's) claim.

r) Appoints the agent of record indicated in Section 1 - Group Information (if any) to represent it in matters of group coverage benefits provided

by University of Utah Health Insurance Plans. This appointment is in effect on the same day as the group coverage(s) and remains in force until

rescinded in writing.

s) Acknowledges that if the Company has an agent, that agent may receive bonuses, commissions, administrative services fees, or other

compensation,

SIGNATURE

Name: Title:

Signature: Date:




Purchaser Standards Intermountain Health Care

The following standards are required of the employer (PURCHASER) to be met and maintained in order to access or continue to access Intermountain Health Care (INTERMOUNTAIN) as part of the Provider Network. Upon request, written documentation may be required to establish compliance to this Exhibit.

A. Good Faith Cooperation: PURCHASER agrees to deal with COMPANY and INTERMOUNTAIN in good faith, refrain from harming the reputation andpublic image of COMPANY and INTERMOUNTAIN, and refrain from public statements that may be damaging to COMPANY or INTERMOUNTAIN.

B. Facility Communication: COMPANY and PURCHASER agree to direct all correspondence they intend to send to Intermountain Facilities throughINTERMOUNTAIN for review and approval prior to distribution to Intermountain Facilities.

C. Identification Card: If COMPANY does not provide Members with a Member identification card, PURCHASER agrees to arrange for the distribution of an identification card to all Subscribers that includes the name of PURCHASER’s plan, PURCHASER’s identification number, the COMPANY service mark, and the toll-free numbers that Intermountain Facilities and Members may use to verify coverage, to obtain authorization for Covered Services, and to review the status of a claim. The identification card will also include the address where claims shouldbe sent.

D. Dispute Resolution: PURCHASER agrees to meet and confer with COMPANY and INTERMOUNTAIN in good faith to resolve any controversies or claims that may arise under this Agreement. Any controversy or claim solely between the parties, relating to this Agreement or the breach of thisAgreement, that is not settled by informal means will be submitted to binding, compulsory arbitration and judgment pursuant to Title 78B, Chapter11, Utah Code Annotated, as amended, and handled in accordance with the Rules of the American Health Lawyers Association Alternative DisputeResolution Service to the extent such rules are not in conflict with such law. Each party agrees to bear its own costs, expenses, and attorney feesarising from such controversy or claim. The parties will share equally the cost of the arbitrator(s).

E. Insurance: PURCHASER agrees to maintain policies of general liability insurance or a comparable program of self-insurance. PURCHASER agrees to provide INTERMOUNTAIN with documentation of such insurance policy or policies upon request.

F. Use and Marketing of Network: PURCHASER is prohibited from marketing or subcontracting the INTERMOUNTAIN Network facilities listed inAttachment B, “Intermountain Facilities and Payment Schedule,” of the UUHP/INTERMOUNTAIN Commercial Agreement and the ProfessionalProviders included on the Professional Provider List, in part or in total, as defined in the of the UUHP/INTERMOUNTAIN Commercial Agreement.

G. Professional Employee Organizations (PEO)/Multiple Employer Welfare Arrangements (MEWA): PURCHASER represents and warrants that its business is NOT that of a:

1. PEO, licensed according to Utah Code Title 31A, Insurance Code, Chapter 40, “Professional Employer Organization Licensing Act”; or

2. MEWA, licensed according to Utah Code Title 31A, Insurance Code, Chapter 13, “Employee Welfare Funds and Plans”.

H. Compliance with Regulatory Requirements: PURCHASER represents and warrants that during the term of this Agreement, it is in compliance with all applicable state and federal laws and regulations governing the subject matter of this Agreement, including any requirements regardingelectronic transactions, confidentiality of individually identifiable health information, disclosure of nonpublic personal information, licensing, and appeals and grievance procedures.

I. Default and Cure: If PURCHASER is in default of any applicable requirement in Sections A-H of this “Exhibit F Purchaser Standards,” INTERMOUNTAIN may give written notice to COMPANY of PURCHASER default. If PURCHASER is unable to cure the default within a reasonable amount of time, INTERMOUNTAIN may upon five (5) days written notice to COMPANY, terminate PURCHASER’s access to the Network and discontinue PURCHASER’s discounts specified in the UUHP/INTERMOUNTAIN Commercial Agreement.

J. Access to Network: Unless specific provisions have been waived in writing by INTERMOUNTAIN, PURCHASER must comply with Sections A-J above, in order to access to the INTERMOUNTAIN Network, as defined in the UUHP/INTERMOUNTAIN Commercial Agreement.

Documents

Group Master Application Level Funded ProductBANKING INFORMATION (for ACH) ... contact your Sales Representative before signing this application. ... All material terms of coverage