Agenda - 4-7-14 Reg. Meeting - Laserfiche WebLink

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G 4 2 Group Application for Blue Cross and Blue Shield of North Carolina Coverage ❑ New Prospect Number: ❑ Renewal N Medical Renewal (No Changes) Group Number: Effective Date: Group Group ❑ Medical Renewal (With Changes) 1 062740 08/01/201 1. Name of Group: Tax ID No (EIN): County of Lee ss - annn.1111 1 2. Physical Address: 408 Summit Drive ADDRESS 1 ADDRESS 2 Sanford NC 27330 Lee CITY STATE ZIP CODE COUNTY Billin Address: PO BOX 1968 (if different from above) ADDRESS 7 ADDRESS 2 Sanford NC 27331 -1968 CITY STATE ZIP CODE 3. Group Administrator: Telephone Number: Fax Number: Email Address: Joyce McGehee (919) 718 -4615 (919) 718 -4628 l jmcgehee@leecountync.gov 4. Divisions /Subsidiaries /Affiliates to be covered (attach list if necessary): Name: Relationship: Address: Nature of Business: 5. Industry Type (NAICS Code): 6. Do any eligible employees reside ❑ Yes If yes, list states: 92111 outside the State of North Carolina? Q No 7. Do you qualify as a ❑ religious employer or an ❑ eligible organization (self- certification documentation is required) as defined under the Patient Protection and Affordable Care Act, 45 CFR §147131? [:]Yes ❑■ No GROUPS 1 -50 ELIGIBLE EMPLOYEES ONLY: 8. Group certifies that it meets the definition of a Small Employer as defined by ❑ Yes ❑■ No the North Carolina Statutes (NCGS 58 -50 -110) and is not a sole proprietorship. 9. The Group certifies that all individuals enrolling for coverage meet the following definition of eligible employee: An eligible employee is an individual working 30 hours or more per week on a full -time basis with the employer reporting the FICA withheld by W2 Form on an annual basis. Persons whose compensation is reported entirely on 1099 Forms are not generally considered eligible. An individual who is a "statutory employee" as that term is defined under Internal Revenue Code Section 3121(d)(3) and works on a full -time basis for the Group may be considered eligible for small group coverage only. Documentation of "statutory employee" status is required. Q Yes ❑ No ELECTED OFFICIALS: 10. If you employ Elected Officials, do you want to provide Elected Official coverage? *Yes ❑ No (Applies to municipalities and county government only) 11. Health and USAble ° Life Products: Eligibility requirements to be applicable to future employees Note: "0 day probationary period" is only available for health coverage for groups of 6 or more eligible employees: ❑■ 1st of the month following 30 days ❑ Next day following 60 days ❑ 0 day, effective on date of hire ❑ Next day following 30 days ❑ Next day following 90 days ❑ Self- funded Groups Only: Other ❑ 1 st of the month following 60 days ❑ 0 day, effective 1 st of the month (not greater than 90 days) following the date of hire 12. Choose one of the following to be applicable to employees terminating health coverage: ❑� End of the contract month following employment termination ❑ Last day of employment (only available to groups of 6 or more eligible employees) GROUPS 51+ ELIGIBLE EMPLOYEES ONLY: 13. BCBSNC standard eligibility allows for persons to be covered who are active, full -time employees, working 30 hours or more per week and their eligible dependents. Underwriting approval is required for any additional eligibility requests. Pre 65 Retirees: (Before Eligible Retiree Coverage) Domestic Partner Coverage Options (check all that apply): EYes ❑ No Q None ❑ Same Sex ❑ Opposite Sex Other Special Eligibility (please specify): independent licensee of the Blue Cross and Blue Shield Ass— ation. T, SM Marks of the Blue Cross and Blue Shleld Asso —tr— �M1 Mark of the Blue Cross and Blue Shield of North Carolina. I1 Mark of USAhle Llfe. Visit us at bcbsnc.com GRPAPPLY, 6/13 B1ueCross B1ueShield of North Carolina PAGE 1 of 4