Minutes - April 16, 2012 Regular Meeting

Home Browse Search

BK00024 PG:0870 Group Application for Blue Cross and Blue Shield of North Carolina Coverage ❑ New Prospect Number: ❑Renewal ® Mediol ftenevval (No Changes) Group Number: 1 Effective Date: Group Group ❑Medical Renewal With Changes) 06274 8/1/2012 1. Name of Group: Tax ID No (EIN): County of 1 ee 1 56 6000313 2. Type of Organization: ❑ Sole Proprietorship ED Partnership ❑Corporation El Trust DOther: Government 3. Physical Address: 106 Rillcrest Drive ADDRESS 1 ADDRESS 2 Sanford NC 27331 Lee CRY STATE ZIP CODE COUNTY Billing Address: PO BOX 1966 (f differem: from above) ADDRESS 1 ADDRESS 2 Sanford NC 27331.1968 i.Yn S471 E ZIP CODE Group Administrator. Telephone Number: Fax Number: Email Address: Joyce McGehee 919 - 7184615 ext5563 c[I9 '7 1$ -4 (D 2 S jtncgehee *1eecountync.gov 4. Divisions /Subsidiaries�Affiliates to be covered (attach list 9 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? ®No GROUPS 1 -50 ELIGIBLE EMPLOYEES ONLY: 7. The Group certifies that it meets the definition of Small Employer Group as follows: any individual or entity actively engaged in business that, on at least fifty percent (50%) of its working days during the preceding calendar quarter, employed no more than 50 eligible employees, the majority of whom ate employed within this State, and is not formed primarily for purposes of buying health insurance and in which a bona fide employer - employee relationship exists. In determining the number of eligible employees, companies that are affiliated companies, or that are eligible to file a combined tax return for the purpose of taxation by the State of North Carolina, shall be considered one employer. ❑ Yes ❑ No S. The Group certifies that all individuals enrolling for coverage meetthe 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 Intemal 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. ❑X Yes ❑ No 9. ELECTED OFFICIALS: If you employ Elected Officials, do you want to provide Elected Official coverage? ® Yes ❑ No (Applies to municipalities and county government only) 10. Health and USAble Life Producer. 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 probationary period, effective on date of hive ❑ Next day following 30 days ❑ Next day following 90 days ❑ 1st of the month following 60 days ❑ 0 day probationary period, effective 1st of the month following the date of hire 11. Choose we of the following to be applicable to employees terminating heath coverage: D End ofthe contract month following employment termination ❑ Last day of employment (only available to groups of 6 or more eligible employees) 12. Pre- existing waiting period options — health only (no visiting periods for those under age 19): Groups 1 -50 Eligible Employees Groups 51+ Eligible Employees []Applies to all timely and late enrollees. ❑Applies to all timely and pate enrollees. []Waived for original effective date ❑ Waived for original effective date enrollees and enrollees, late enrollees delayed to open subsequent timely enrollees. Applies to late enrollees. enrollment. Applies to subsequent timely and late enrollees. ❑1Naived for all enrollees timely and late. ® Waived for original effective date enrollees. 13. GROUPS 51+ ELIGIBLE EMPLOYEES: 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 additbnal eligibility requests. Domestic Partner Coverage Options Pre 65 Retirees: Other Special Eligibility (please specify: (check all that apply): (Before Eligible Retiree Coverage) ❑X None ❑Same Sex ❑Opposite Sex ®Yes ❑No pre65retirees and govt officials