Minutes - April 16, 2012 Regular Meeting

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BK:00024 P(Gii0869 Group Name ..0t- n jf _C) p Payment Options: Complete for Health and USAble Life Products 28. 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 9 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 websfte (w vv.bebsnc.eom /employedservkes) and 1 will not receive a paper invoice. ❑ Automatic Bank Draft - withdraw the Group's initial and subsequent monthly premium 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, than log -in to BCSSNCs Employer Services websire each month to make payments. ❑ Paper Transactions - enclose a check or withdraw the Group's initial premium payment. Future monthly payments will be made by check upon receipt of a paper Invoice. Name of Bank Account Holder: Name of Bank: Bank Routing Bank Account Transit Number: Number: This number appears in the lower left -hand This number appears to the right of the transit number and is comer of your check, separated from the transit number by symbols/spaces. Your number Signature of may be shorter than the boxes provided above. Account Holder or Authorized User: X Date: MM /DDMrYY 29. 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. 30. Effective Date of Coverage: Subject to the acceptance of this application by BCBSNC at its home office and the payment of applicable fees, the effective date of coverage for the group health plan, pursuant to this application, shall be 12:01 AM Eastern time on the day of (month),_ (year). 31. 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 arcuate. 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 administrators 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 Contacts 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. If Group is purdhasing Life, ADD and(or STD, my signature further represents the GroulYs obligation to pay the applicable premiums associated with those products. I 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 mrra � / t is al requ' d. [� Signature of Authorized Official: r� _ Date: I j � G L / } MM1DD•YYrY Print Name: 7,f p dn, 1 • v Title: l .YIa IY i Producer Name: Mark Browder Date: 3/13/2012 Producer Number: P0012238 MWDDn9YY F P — ATE T,7-4