Medical / Dental / Life / VisionEnrollment Application721 South Parker, Suite 200, Orange, CA 92868(800) 558-8003 www.calchoice.comCOMPLETE WAIVER SECTION ON PAGE 4 IF YOU OR ANY OF YOUR DEPENDENTS ARE NOT ENROLLING.COMPLETE AN EMPLOYEE CHANGE REQUEST FORM IF YOU ARE AN EXISTING MEMBER AND NEED TO MAKE CHANGES.FOR PRIMARY CARE PHYSICIAN CHANGE ONLY, PLEASE CONTACT YOUR HEALTH PLAN DIRECTLY.New BusinessSelect oneANew HireNew RenewalNew COBRAQualifying/Triggering EventPersonal InformationCompany NameGroup #Employee Job TitleFull-Time Employment Date (MM/DD/YYYY)MGenderFMarriedStatusSingle(exclude any orientation periods, if applicable)Domestic PartnerEmployee Social Security #Employee Last NameM.I.Employee First NameHome Phone # (XXX) XXX-XXXX-E-mail Address-Physical Address (Do not use P.O. Box)StateZIP CodeBApt. #CityApt. #CityCountyMailing Address (if different from above)StateDate of Birth (MM/DD/YYYY)ZIP CodeCountyEnrollment InformationComplete this section ONLY if you are electing medical, dental and/or vision for yourself and dependents.EmployeeChild 1Spouse/Domestic PartnerChild 2Child 3Life onlyMedicalDentalVisionEnrolling entalVisionMedicalDentalVisionLast NameFirst NameSpouseRelationship to EmployeeDomesticPartnerSocial Security # required!Social Security #MaleGenderSocial Security # required!FemaleMM/DD/YYYYDate of BirthDisabled?MaleYes(Complete only if over age 26)FemaleMM/DD/YYYYNoSocial Security # required!MaleFemaleSocial Security # required!MaleMM/DD/YYYYYesFemaleMM/DD/YYYYNoYesNo To enroll more dependents, complete sections A & B on an additional application.COBRA ApplicantsPlease checkCOBRA typeCOBRACal-COBRADate of Qualifying/Triggering EventIndicate Qualifying/Triggering EventTermination of employmentReduction of hoursChild no longer eligibleDivorce/legal separation(MM/DD/YYYY)Medicare entitlementDeath of employeePLEASE SIGN AND DATE APPLICABLE SECTIONS INSIDE APPLICATION(1 of 5)CC 0310 3/2020 Eff. 7/1/2020License # 0B42994 - CaliforniaChoice Benefit Administrators, Inc.61487
Group #Print Employee NameCDMedical Benefit -IMPORTANT: Please select ONE benefit plan from the metal tier(s) shown on your Enrollment Worksheet.HEALTH PLANBRONZESILVERGOLDPPO APPO BPPO CHMO AHMO BPPO APPO BPPO CHMO AHMO BHMO CHMO DHMO EHMO FPLATINUMPPO EHMO APPO A*PPO B*HMO AHMO BEPO AEPO AEPO B*HMO AHMO AHMO CKAISERPERMANENTEHMO AHMO C*HMO AHMO BHMO COSCAREPO A*EPO BEPO A*EPO BEPO CEPO AEPO BEPO CEPO DEPO AEPO BSHARPHMO AHMO B*HMO AHMO BHMO CHMO AHMO BHMO DHMO AHMO BSUTTER HEALTHPLUSHMO AHMO B*HMO BHMO C*UNITEDHEALTHCAREHMO AHMO B*HMO AHMO BHMO CHMO DHMO AHMO BHMO CHMO AHMO BWESTERN HEALTHADVANTAGEHMO BHMO C*HMO AHMO BHMO C*HMO AHMO BHMO CHMO D*HMO AHMO BANTHEMBLUE CROSSHEALTH NETPPO DHMO D*HMO CHMO DHMO EHMO AHMO BHMO AHMO BHMO AHMO BHMO CHMO AHMO BHMO C*HSA Qualified High Deductible PlanSpouse/Domestic PartnerEmployeeChild 1Child 2Child 3Primary Care Physician**Current Patient?YesNoYesNoYesNoYesNoYesNoProvider ID#Provider CityCheck here if you would like your Health Plan to assign you a Primary Care Physician.** A Primary Care Physician (PCP) is not required for Kaiser Permanente, EPO and PPO benefit plans. If a PCP is not contracted with your selected HealthPlan prior to enrolling or if a PCP is not listed, one will automatically be assigned to you.DOptional Benefits - Ask your health plan administrator if any of the optional benefits below are being offered by your employer.Sections A, B & E of this application must be completed for all Optional Benefits.Life InsuranceBeneficiary Name(s)Last NameFirst NameM.I.Date of BirthRelationship to You(i.e. spouse, friend, child)***Percentage*** Type rimarySecondaryMM/DD/YYYYPrimarySecondary*** If you are listing more than one primary beneficiary or more than one secondary beneficiary, please enter the percentage of the insurance proceeds thateach individual should receive. The percentage of insurance proceeds must equal 100% for each type of beneficiary (primary or secondary). No secondarybeneficiaries will be entitled to any part of the insurance proceeds if any primary beneficiary is living at the time of death of the insured.Dental CoverageSmileSaver DHMO †30001000Ameritas PPO30003500† SmileSaver DHMO plans require selection of a40005000Check if dentist chosen is current providerCheck if you would like a dentist assignedDentist Name / Office (If left blank or dentist is unavailable, one will be assigned) ID#family dentist. Upon receipt of dental ID cards, youmay elect other dentists for dependents.Vision Coverage – IMPORTANT: Please select ONE benefit plan belowVoluntary EyeMed (provided by Ameritas)*Voluntary VSP (provided by Ameritas)*Vision One Discount Plan (No Charge)*Employee is responsible for 100% of this cost if selected for coveragePremium Only Plan (P.O.P.)I want my portion of eligible insurance premiums paid on a pre-tax basis61487(2 of 5)CC 0310A 3/2020 Eff. 7/1/2020License # 0B42994 - CaliforniaChoice Benefit Administrators, Inc.
Group #Print Employee NameEYour Legal Acknowledgement andMandatory Binding Arbitration Agreement(Read, sign and date where indicated)By submitting this signed application, I agree and understand that the health plan I have chosen through the CaliforniaChoice program shallautomatically have a lien on any payment of monies from any source, for services rendered in conjunction with an injury caused by the acts or omissions of athird party.I agree for myself and my dependents to be bound by the benefits, copays, deductibles, exclusions, limitations and other terms of the health plan’s smallgroup contract.I authorize my physician, healthcare provider, hospital, clinic or other medically related facility to furnish my, and my dependent’s, protected healthinformation, including medical records, to the health plan I have chosen through the CaliforniaChoice program or its authorized agents for the purpose ofreview, investigation, or evaluation of an application or claim, and for quality assurance and utilization review. I authorize CaliforniaChoice and the health planI have chosen, and their agents, designees or representatives, to disclose to a hospital, health plan, insurer or healthcare provider any protected healthinformation if such disclosure is necessary to allow the performance of any of those activities. This authorization shall become effective immediately and shallremain in effect for up to 30 months from the date the authorization was signed. I understand that I, or a person authorized to act on my behalf, is entitled toreceive a copy of this authorization form.I have read and understand the information provided to me pertaining to the Premium Only Plans and the tax consequences.I declare under the penalty of perjury under the laws of the state of California that the following statements are true, correct and pertain to theemployer named on this application, myself and my dependents named on this application. I am either actively, permanently working for the employer and considered eligible by my employer because I work either 20 or 30 hours per week, or Iam an eligible COBRA/Cal-COBRA participant. I am not a temporary, seasonal, per diem, 1099 or substitute employee or insured by or eligible to be insured by the employer’s union policy. My children’s dates of birth are accurate. My children are born to me or my spouse/domestic partner, or legally adopted, or a nontemporary legal ward,and/or have an established parent-child relationship with me or my spouse/domestic partner. I understand that I am required to notify CaliforniaChoicewhen an established parent-child relationship ceases to exist.I understand that the preceding statements are subject to audit at any time and agree to provide CaliforniaChoice with any and all information necessary toprove the above statements.All statements and answers I have given are true and complete. I understand it is a crime to knowingly perform an act or practice constituting fraud or makean intentional misrepresentation of material fact to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment,fines or a denial of insurance benefits. I understand all benefits are subject to conditions stated in the Group Contract and coverage documents. If my plan isrescinded or canceled, I will receive from my insurer a notice at least 30 days prior to the effective date of the rescission explaining the reasons for theintended rescission and my right to appeal that decision to the Commissioner of Insurance pursuant to subdivision (b) of Section 10273.4 of the CaliforniaInsurance Code. Notwithstanding subdivision (a) of Section 10273.4 or any other provision of the law, I understand that after 24 months following the issuanceof my health plan or insurance policy, my insurer may not rescind my health plan or insurance policy for any reason, and shall not cancel my health plan orinsurance policy, limit any provisions of the health plan or policy, or raise premiums due to any omissions, misrepresentations, or inaccuracies in theapplication for, whether willful or not.I understand that any persons, business or health plan that suffers a loss because of false-declarations contained in this statement may take legal actionagainst me to recover their losses. The representations made are the basis upon which coverage may be issued. The coverage may be cancelled or the employer’s contract rescinded because of the performance of an act or practice constituting fraud or making of anintentional misrepresentation of a material fact to an insurance company for the purposes of defrauding the company. I have READ, UNDERSTAND and ATTEST that I myself and my dependents have met all of the eligibility requirements.California law prohibits an HIV test from being required or used by health care service plans as a condition of obtaining coverage.MANDATORY BINDING ARBITRATIONI understand that, if I select a Health Plan that uses mandatory binding arbitration to resolve disputes, I am agreeing toarbitrate claims that relate to my or a dependent's membership in the Health Plan (except for Small Claims Court casesand claims that cannot be subject to binding arbitration under governing law). I understand that any dispute betweenmyself, my heirs, relatives, or other associated parties on the one hand and the Health Plan, any contracted healthcare providers, administrators, or other associated parties on the other hand for alleged violation of any duty arisingout of or related to membership in the Health Plan, including any claim for medical or hospital malpractice (a claim thatmedical services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), forpremises liability, or relating to the coverage for, or delivery of, services or items, irrespective of legal theory, must bedecided by binding arbitration under California law and not by lawsuit or resort to court process, except as applicablelaw provides for judicial review of arbitration proceedings. I agree to give up our right to a jury trial and accept the useof binding arbitration. I understand that the full arbitration provision is in the Health Plan's coverage document, whichis available for my review.Employee SIGN HERE FOR MEDICAL, DENTAL, LIFE OR VISION COVERAGEPrint NameToday's Date (MM/DD/YYYY) My signature acknowledges that I have read Section E, the applicable mandatory binding arbitration of the plan I selected in Section C and mydecision to enroll in the medical, dental, life or vision coverage that I selected in Sections C and D.61487(3 of 5)CC 0310B 3/2020 Eff. 7/1/2020License # 0B42994 - CaliforniaChoice Benefit Administrators, Inc.
MEDICAL / DENTAL WAIVERIMPORTANT!Complete this page only if you DO NOT WANT MEDICAL OR DENTAL COVERAGE for yourself and/or your eligible dependents. Ifoffered by your employer, the life coverage benefit cannot be waived and you are required to complete an Enrollment Application.Chiropractic coverage cannot be waived when enrolling for medical coverage.APersonal InformationCompany NameCompany Phone # (XXX) XXX-XXXXEmployee Last NameEmployee Social Security #Group #Employee First NameB-Type of WaiverI have been offered coverage by my employer, but at this time I wish to DECLINE coverage as followsC1)Medical forMyself and DependentsSpouseDomestic PartnerChild(ren)2)Dental forMyself and DependentsSpouseDomestic PartnerChild(ren)ReasonRequired only if employee waiving coverage - not required if waiving coverage for dependents only1)Reason waiving MedicalCarrier NameGroup #Other Group CoverageMedicareMedi-calIndividual Policy(explanation required)Other Reason2)Reason waiving DentalCarrier NameGroup #Other Group CoverageMedicareMedi-calIndividual Policy(explanation required)Other ReasonDSignatureI understand that by failing to elect coverage now, CHOICE Administrators Insurance Services, Inc. will require me to wait to enroll until myemployer group's next open enrollment period, unless I experience a qualifying/triggering event that would allow me to enroll for coverage priorto open enrollment.I understand that by failing to elect DENTAL coverage now, CHOICE Administrators Insurance Services, Inc. can also impose a 6 monthpre-existing condition exclusion, both of which would begin at the time of my later decision to elect DENTAL coverage.I also understand that if my employer is offering life coverage, I CANNOT WAIVE LIFE COVERAGE.This waiver provision will not apply if: 1) Court orders coverage of a spouse or child and the request for enrollment occurs within 60 days of thecourt order; or 2) Employee meets ALL of the following: A) Was covered under another employer-sponsored health plan at the time of initialeligibility; B) Has added a new dependent as a result of marriage, domestic partnership, birth, adoption, or placement for adoption or has assumed aparent-child relationship and if enrollment is requested within 60 days after the marriage, domestic partnership, birth, adoption or placement foradoption or has assumed a parent-child relationship OR employee or eligible dependents loses minimum health care coverage, for any reason otherthan due to failure to pay premiums, fraud, or intentional misrepresentation of material fact; C) Requests enrollment within 60 days of loss ofcoverage.Employee SIGN HERE TO WAIVE COVERAGEPrint NameToday's Date (MM/DD/YYYY) Validate My Form(4 of 5)CC 0310C 3/2020 Eff. 7/1/2020License # 0B42994 - CaliforniaChoice Benefit Administrators, Inc.61487
721 South Parker, Suite 200, Orange, CA 92868(800) 558-8003 www.calchoice.comWho can be covered? Effective datesNew Spouse/New StepchildFamily CoverageEligibility RequirementsRequirements that MUST be metIf all required documentation is receivedbefore the 16th day of the month ofmarriage, premiums are charged for thefull month and coverage begins on the dateof marriage. New spouse must be legally married to the employee New stepchild must also meet the dependent children requirements listed belowIf all required documentation is received onor after the 16th day of the month ofmarriage, coverage begins on the 1st ofthe month following the date of receipt.Birth/Adoption/Legal Guardianship/Eligible DependentChildIf birth/date of placement occurredbefore the 16th of the month, coveragebegins on the first day of the month of thedate of birth/placement.If birth/date of placement occurred on the16th or after, child is automatically coveredat no cost under Subscriber between dateof birth/placement and the first of thefollowing month. Coverage for thedependent begins on the first of the monthfollowing the birth/date of placement.MEDICAL, CHIRO, VISION and SMILESAVER DENTAL Dependent eligibility: Born to, a stepchild or legal ward of, adopted by, or have an establishedparent-child relationship with the eligible employee, employee spouse ordomestic partner Under age 26 (unless disabled, disability diagnosed prior to age 26)AMERITAS DENTAL Dependent eligibility: Born to, a stepchild or legal ward of, adopted by, or have an establishedparent-child relationship with the eligible employee, employee spouse ordomestic partner Financially dependent upon the employee per IRS guidelines Unmarried or not involved in a domestic partnership Under age 26 (unless disabled, disability diagnosed prior to age 26)Disabled Dependents: Dependents who are incapable of self-supportbecause of continuous mental or physical disability that existed before the agelimit are eligible for coverage until the incapacity ends. Documentation ofdisability will be requested. Once the child reaches the age limit for coverage,verification of eligibility will occur annually at the child’s birthday.Dependents must meet all requirements listed in order to beeligible for enrollmentDomestic Partner/Child of DomesticPartnerDuring Initial Enrollment or Group’s AnnualRenewal:Coverage begins on group’s effective date.Involuntary Loss of Other Coverage:Domestic Partner can be added outside ofRenewal only if he/she loses othercoverage involuntarily. Coverage iseffective the first of following month.Mid-Year Addition: Mid-year additions of adomestic partner will require astate-stamped copy of the Declaration ofDomestic Partnership from the CaliforniaSecretary of State within 60 days ofissuance. If domestic partners have filed aDeclaration of Domestic Partnership andhave not yet received a copy from the state,a signed Affidavit of Domestic Partnershipwill be accepted. Domestic Partners agreeto provide a copy of the Declaration ofDomestic Partnership within 60 days ofissuance. If all required documentation isreceived before the 16th day of the month inwhich the domestic partnership wasestablished, premiums are charged for thefull month and coverage begins on the dateof the event. If all required documentation isreceived on or after the 16th day of themonth in which the domestic partnershipwas established, coverage begins on the1st of the month following the date ofreceipt.For a Domestic Partner to qualify, Employee and Domestic Partner must: Both have filed a duly executed Declaration of Domestic Partnership with theSecretary of State and will provide copies to CaliforniaChoice within 60 daysof its issue. Agree to notify CaliforniaChoice immediately upon termination of domesticpartnership.Children of Domestic Partner must also meet the dependent childrenrequirements listed aboveEmployee and Domestic Partner must meet all requirementslisted in order to be eligible for enrollment61487(5 of 5)CC 0310D 3/2020 Eff. 7/1/2020License # 0B42994 - CaliforniaChoice Benefit Administrators, Inc.
Dental Vision Medical Dental Vision Medical Vision Dental Medical Dental Vision Medical Dental Vision Employee Job Title Home Phone # (XXX) XXX-XXXX - - State ZIP Code State ZIP Code County Date of Qualifying/Triggering Event (MM/DD/YYYY) COBRA Cal-COBRA PLEASE SIGN AND DAT