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

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Payment Options: Group Name: County of Lee G 4 5) Complete for Health and USAble Life Products 30. Authorization for Bank Draft By signing below, I certify that I am an authorized user of the bank account designated below ( "Bank Account "). I hereby request and authorize Blue Cross and Blue Shield of North Carolina (BCBSNC) to charge the initial and /or subsequent premium payments, payments for health and USAble Life products, as designated below, to the Bank Account payable to the order of BCBSNC. I agree that BCBSNC's rights in respect to the bank draft shall be the same as if it were a check drawn on the Bank Account and signed by me or another authorized user. I also authorize the financial institution to reduce the balance of the Bank Account by the amount of the bank draft. I agree that if such charges be dishonored, whether with or without cause and whether intentionally or inadvertently, BCBSNC shall have no liability whatsoever even though dishonor results in forfeiture of insurance. Finally, I understand that unless noted below all invoices will be available on the BCBSNC's Employer Services website (www.bcbsnc.com/employers) and I will not receive a paper invoice. New Groups: ❑ Automatic Bank Draft - withdraw the Group's initial and subsequent monthly premium payments (recurring payments). This authorization will remain in effect until an authorized representative of the Group revokes it in writing at least 10 days prior to the date the account is scheduled to be charged. ❑ Monthly Payments Online - withdraw the Group's initial premium payment (a one -time payment). The Group will log in to BCBSNC's Employer Services website for each additional month they would like drafted. ❑ Paper Transactions - A check is enclosed for the premium payment. Future monthly payments will be made by check upon receipt of a paper invoice. Renewing Groups: The automatic bank draft options shown above are available to renewal groups as well. Renewal groups may elect the desired options by logging in to BCBSNC's Employer Services web site at bcbsnc.com /employers. Name of Bank Account Holder: N/A Bank Routing Transit Number: This number appears in the lower left -hand corner of your check. Signature of Account Holder or Authorized User: X Name of Bank: Bank Account Number: This number appears to the right of the transit number and is separated from the transit number by symbols/spaces. Your number may be shorter than the boxes provided above. Date: MM /DD/YYYY 31. GROUPS 51+ ELIGIBLE EMPLOYEES: In applying for this coverage, the Group understands that it is responsible for reaching an agreement with the producer regarding health commission payments. While BCBSNC is not responsible for producer health commissions, BCBSNC is available to help facilitate the process. A separate agreement where BCBSNC will bill the Group and accept producer health commissions from the Group on behalf of a producer is available. 32. Effective Date of Coverage: Subject to the acceptance of this application by BCBSNC at its home office and the payment of applicable fgges, the effective date of coverage for the group health plan, pursuant to this application, shall be 12:01 AM Eastern time on the 1 day of A (month), L Iyear). 33. Statement of Understanding: Insured Groups Only (all sizes): By signing below, I certify that I am the authorized signer on behalf of the Group and that all information provided is complete and accurate. I further understand that submission of this application and requisite fees constitutes an offer and a binding contract upon acceptance, as applicable, by BCBSNC and BCBSNC's chosen HSA administrator. Acceptance of the offer by BCBSNC and the HSA administrator shall be signified by the earlier of the following events: BCBSNC's issuance of the Group Contract and the HSA administrator's issuance of its HSA Administrative Services Agreement (HSA ASA) (collectively "the Contracts "), or issuance of identification cards to the Group's members. The Contracts issued by BCBSNC and the HSA administrator shall set out the terms of the agreement between the parties, and this application shall be incorporated therein by reference. Group agrees that the Contracts shall be binding upon the parties as issued, without the necessity of signature by the Group. A representative sample of the Contracts are available upon request. References to the HSA administrator and the HSA ASA in this document shall apply only if HSA services are being purchased by Group. If I am an employer with 1 to 9 employees, I further understand that the Life and Accidental Death and Dismemberment and Short Term Disability coverage is provided through a policy issued to the Trustee of the USAble Life Group Insurance Trust, and I hereby apply for participation in said trust, which is insured by USAble Life. A copy of the trust is maintained in USAble Life's home office in Little Rock, Arkansas and is subject to examination by participating employers and USAble Life. Self Funded Groups: By signing below, I certify that I am the authorized signer on behalf of the Group and that all information provided is complete and accurate. understand that as a self- funded group the Group will enter into an Administrative Services Agreement (ASA) with BCBSNC for claims administration that requires a separate signature. If Group is purchasing HRA/FSA Administration through BCBSNC or HSA Administration through another administrator a separate contract is also required. Signature of Authorized Official: Email Address: cparks @leecountyn Date: MM /DD /YYYY Print Name: Charles J. Parks Producer Name: Mark Browder Title: Chairman of County Commissioners Producer Number: P 0012238 Date: MM /DD/YYYY PAGE 4 of 4