Okaloosa County BOCC — August 18, 2015 — Florida Blue Employer Application

Florida Blue B EMPLOYER APP.LIC.ATION (True Group Application) An Independent Licenses of the Blue Cross and Blue Shield Association D New Business E] Renewal Business D Other I I. Group Information Group # (Florida Blue): (Florida Blue HMOY): | _ =] A. Name of Group: ngAl.OOSA CO BOARD OF CO COMMISSIONERS | Nature of Business: |GENERAL GOVERNMENT, NEC | SIC Code: |9199 ] Mailing Address: IEOIA NORTH PEARL STREET, SUITE 204 CRESTVIEW,FL 32536 —I Email Address: LLKI;ORTER@CO.OKALOOSA.FL.US | Listlli)cealggvnSubsidiary or Affiliated Companies whose employees are to be eligible and included with this iIF;Fr)ne ' Address B. Applicant hereby applies for issuance of a Group Policy (herein referred to as a Policy) by Blue Cross and Blue Shield of Florida, Inc., D/B/A Florida Blue and/or Health Options, Inc., D/B/A Florida Blue HMO. Upon acceptance of this application by Florida Blue and/or Florida Blue HMO, it will become part of the Policy issued to the applicant named above. C. PriorInsurance Carrier: Insurance [HUMANA l HMO [NO GROUP INSURANCE | D. The Policy excludes expenses for any service or supply to diagnose or treat any Condition from or in connection with an Insured's job or employment (e.g., any service or supply which is covered by Workers' Compensation insurance) except for medically necessary services (not otherwise excluded) for an individual who is not covered by Workers' Compensation and that lack of coverage did not result from any intentional action or omission by that individual. The foregoing exclusion applies to an individual who elects exemption from Workers' Compensation coverage and to an individual who foregoes Workers' Compensation coverage available to employees in the Group. E. Workers Compensation Carrier is: lSELl-‘ INSURED 1I. Effective Date/Eligibility Information A. Effective Date of this Policy shall be Effective Date of this Change to the Policy shall be This Policy may be terminated by the applicant or Florida Blue/Florida Blue HMO by giving at least 45 days prior written notice to the other party except in the case of non-payment of Premium, B. Only eligible employees who regularly work a minimum of hours each week and their eligible dependents, shall be eligible for coverage upon the Effective Date of this Policy. C. Specify classification of enrollees for whom coverage is being requested, if other than eligible employees as described in B above. Eligibility - Full Time Employees - Ist of the Month 30 Days. Dept Heads - 1st of the Month following DOH Eligibility - Termination is as of the end of month, the benefits are termed as of the end of month. With the exception of termination due to misconduct or mischievous conduct, then termination of benefits is as of the date of termination. D. New eligible employees may be covered effective on the Ist of the month | after [See SpecIns | days of employment, so long as the eligible employee submits an application to Florida Blue/Florida Blue HMO within 30 days of the date the individual first meets the applicable eligibility requirements. E. Atleast % of the eligible employees must be enrolled under the Policy on the Effective Date and throughout the term of the Policy and the Group must meet and continue to meet Florida Blue/Florida Blue HMO participation requirements. F. Florida Blue/Florida Blue HMO shall have the right to audit the applicant's payroll records at any time to confirm eligibility for coverage, including participation percentage criteria required by Florida Blue/Florida Blue HMO. Applicant agrees to furnish any such request. G. Employer Contribution: Employee: % Dependents: |I|% 13123-0813R 07/31/2015 1:06:52 PM Florida Blue &Y An Independent Licensee of the Blue Cross and Blue Shield Association EMPLOYER APPLICATION (True Group Application) II1. Health Plan Summary Information (select the appropriate box[s]): Included in Product Accept Decline 0O O X O O O O O 0O Mandated Benefit Offerings:(Optional)