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Small Employer Health Plus Plan

along with a Small Employer Health Plan

NEW CASE SUBMISSION MATERIALS CHECKLIST

1) Submit Bundled Benefit and Rate Sheet (pdf generated by HealthConnect) OR applicable plan

benefits sheet within marketing brochure.

2) Complete the following applications:

a. Application for a Small Group Health Benefits Policy – form 32327 (1020)

i. Select Horizon Family Grins for low package option

ii. Select Horizon Family Grins Plus for high package option

b. Application for Vision Benefits through Small Employer Health Plus- form 32335 (0918)

i. Select Horizon Vista for low package option

ii. Select Horizon Panorama IV (Alt B) for high package option

c. USAble* Application-form ICC21-SG2-APP (3-21)

i. Complete application

ii. Groups with the following SIC codes are ineligible: 14xx, 2892-2899, 3292, 45xx, 7381,

88xx, 9999

iii. Beneficiary forms are retained by the group

Important notes:

 Deposit premium is required for the health plan.

 For Dental and Vision, you must select either both low package options or both high package

options.

 For employees who waived health coverage and would like to enroll in Small Employer Health

Plus, submit completed Enrollment/Change Request forms.

3) Submit applications to your Horizon Master Broker.

*USAble Life is an independent company that operates separately from Horizon BCBSNJ. USAble Life does not sell or

service Horizon BCBSNJ products and is solely responsible for the life, disability and accident products referenced herein.

Life insurance policy is issued and billed directly by USAble. Please call (800) 370-5856 for questions regarding the Life and

AD&D portion of the program.

32336 (W0318)

Small Employer Group Application Instructions

Instructions The attached forms should be completed with the assistance of your authorized Broker or

Horizon Blue Cr oss Blue Shield of New Jersey Sales Representative.

Please complete all necessary forms in their entirety. Please print in ink or type your responses.

Ensure that all areas requiring a signature and date are complete. The Officer, Partner, Owner and / or

Correspondent signing the application must be listed on the New Jersey Sma l l Employer Certific a t i on.

Completed enrollment application forms should be sent to your authorized Broker or Horizon

BCBSNJ Sales Representative prior to your effective date.

Documents Attached you will find the forms that must be compl e t e d and submitted for each New Jersey small

Included employer group applying for standard health insurance coverage:

• Application for a Small Employer Health Benefits Policy.

• New Jersey Small Employer Certification.

• Small Employe r Healt h Benefits Waiver of Coverage – One form is needed for each employee

waiving or refusing coverage. This form may be photocopied as needed.

Other Required In addition to the forms listed above, depending on group size / composition and preferred

Documents payment method, the following items may also be required:

• Payroll verification through appropriate tax documentation, i.e., WR30 (required for groups of five or

fewer eligible).

• Owner payroll documentation (K-1, Schedule C and/or 1120).

• Automatic Pay Plan Application (#8977).

When submitting your paperwork as required above, you must also submit the following:

• Enrollment Change / Request Form (#6803) – One form is ne e de d for each employee enrolling. Your

authorized Broker or Horizon BCBSNJ Sales Representative will provide these forms.

• First month’s premium – All new cases must be submitted with a company check for the first month’s

premium payable to Horizon BCBSNJ. If a case is submitted without a premium check, the case will

be returned.

•Prior/CurrentCarrier’smostrecentbillingstatement–Requiredifreplacinggroupmedicalcoverage.

• Rate Quote – T he rate quote generated for the group should match the product(s) selected in

Section II of the Application for a Small Employer Health Benefits Policy.

Rate Quotes The rate quote is an estimate based on information provided by your authorized Broker or Horizon

BCBSNJ Sales Representative. If there is inaccurate or missing information on the original quote, the

rate may change based on an official review of the paperwork submitted to Horizon BCBSNJ.

Submission

of Application

to Horizon

BCBSNJ

Your authorized Broker will submit this Application to Horizon BCBSNJ.

ServicesandproductsmaybeprovidedbyHorizonBlueCrossBlueShieldofNewJersey,orHorizonHealthcareofNewJersey,Inc.,bothofwhichareindependentlicensees

oftheBlueCrossandBlueShieldAssociation.TheBlueCross®andBlueShield® namesandsymbolsareregisteredmarksoftheBlueCrossandBlueShieldAssociation.

TheHorizon®nameandsymbolsareregisteredmarksofHorizonBlueCrossBlueShieldofNewJersey.

32327(1020)

•

Where there is an affiliated company, a Small Employer Common Ownership Certification form.

1. Policyholder (full legal name of company): _______________________________________________________________________________________________

2. Tax Identification Number: _______________________________________________________________________________________________________

3. Main Address: _______________________________________________________________________________________________________________________

Street City State ZIP

Mailing Address: _____________________________________________________________________________________________________________________

Street City State ZIP

Telephone: _______________________________ Facsimile: _____________________________ Email Address: ______________________________

Contract information should be provided:

! electronically or ! hard copy. Check one.

4. Correspondent: _______________________________________________________________ Title: __________________________________________________

5. Type of Organization: ! Corporation ! Partnership ! Proprietorship ! Other (explain): ________________________________________

6. Nature of Business (specify): _________________________________________________ SIC Code: ________________________________________

7. Number of full-time employees in your company: _________________

Refer to the New Jersey Small Employer Certification for the definition of a full-time employee.

8. Number of full-time employees to be insured: _____________________ 9. Class or classes to be excluded: __________________________

10. Insurance Requested For:

! Employees Only ! Employees and Dependents including Spouse ! Employees and Dependents excluding Spouse

Should the plan provide coverage for domestic partners as permitted by P.L. 2003, c. 246?

! Yes ! No

If yes, should the plan provide coverage for coverage of children of a covered domestic partner? ! Yes ! No

11. Is the employer subject to the requirements of COBRA? ! Yes ! No

12. Is the employer subject to the requirements of Medicare as Secondary Payor Rules for eligibility due to age?

! Yes ! No

Due to disability? ! Yes ! No

13. Orientation Period? ! Yes ! No

14. Waiting period before employees become insured: (may not exceed 90 days)

Present Employees : ! no waiting period ! one month ! two months ! 90 days

New or Rehired Employees: ! no waiting period ! one month ! two months ! 90 days

15. Period for Annual Employee Open Enrollment Period: __________________________________________________________________________________

16. What percentage of the premium will the employer pay? _______________

17. Deposit $ ________________

Premium Paid: ! Monthly ! Automatic checking withdrawal

Premium will be due as of the effective date. The premium for the first month of coverage must be attached.

Affiliates, subsidiaries or branches (Must be included for purposes of participation)

SECTION I: POLICYHOLDER INFORMATION

Legal Name & Location

No. of full-time employees

in this company

No. of full-time employees

to be insured

APPLICATION FOR A SMALL GROUP HEALTH BENEFITS POLICY

Please print or type Policy Number: ____________________________ ! New Policy ! Change in Policy Requested Effective Date: __________________

Note: The Effective Date will be on or after the date Horizon Blue Cross Blue Shield of New Jersey approves the application.

32327 (1020)

RESET

SECTION II: SPECIFICATIONS FOR COVERAGE

Please select desired health benefits option and stand alone pediatric dental option.

HEALTH BENEFITS

Advantage Direct Access

! Platinum 100/70 - $20/$40 copay, $10/$25/$50 Rx, with BlueCard

!Gold 100/80/60 - $30/$0 copay, $15/$40/$75 Rx, with BlueCard

AdvantageEPO

! Gold 100% - $25/$45 copay, $25/$50/$75 Rx

! with BlueCard ! without BlueCard

! Gold 100% - $40/$60 copay, $15/60%/50% Rx

! with BlueCard ! without BlueCard

! Gold 100/80 - $20/$40 copay, $10/$25/$50 Rx

! with BlueCard ! without BlueCard

!Silver100/70-$45/$70copay,$2/$50/$75Rx

! with BlueCard ! without BlueCard

!Silver100/50-$30/$60copay,$20/$0/$75Rx

! with BlueCard ! without BlueCard

OMNIA

! OMNIA Platinum, $5/$15/$30/$30 Rx, without BlueCard

! OMNIA Gold, $10/$40/$75/$75 after Tier 1 Rx deductible, without BlueCard

OMNIA Silver

Value, $10/$40/$75/$75,

after Tier 1 deductible, without BlueCard

HSA plans

! OMNIASilverHSA,Tier1deductible&60%Rx,withoutBlueCard



! HSA

Advantage Direct Access Silver 100700 - $30/$50 copay, 60% CDHRx, with BlueCard

! Other: ____________________________________________________________________________________________________________

STAND ALONE PEDIATRIC DENTAL

! Horizon Young Grins (only provides benefits for members under age 19)

! Horizon Family Grins

! Horizon Family Grins Plus

STAND ALONE PEDIATRIC DENTAL OPTIONS

The Patient Protection and Affordable Care Act (PPACA) permits plans outside of the Small Employer Business Health Options (SHOP) Program

to issue coverage without pediatric dental benefits only if reasonably assured that the applicant has purchased an exchange-certified stand-alone

dental plan (SAPD) covering the pediatric dental benefits as required by PPACA. In order to receive reasonable assurance from you, we require

the following information if you did not select a Stand Alone Pediatric Dental Plan listed above:

! Proof of coverage or other documentation reasonably acceptable to the Health Insurance Issuers evidencing your enrollment in an exchange

certified SAPD. Proof acceptable may be a copy of enrollment confirmation from the SAPD issuer or a copy of your coverage document (for

example, a certificate of coverage).

! The contact information of your SAPD issuer that we may verify your enrollment with, which you expressly grant our ability to verify your

enrollment:

Name of SAPD Issuer: ________________________________________________________________________________________________

Policy Number: ______________________________________________________________________________________________________

Name of Contract Holder: ______________________________________________________________________________________________

32327 (1020)

/-.)! "RONZE $25/50%, 50%, 50% after Tier 1 deductible, without BlueCard

OMNIA Gold, $10/$40/$75/$75 Rx, with BlueCard

OMNIA Silver, $25/50%/50%/50% after Tier 1 Rx deductible, with BlueCard

OMNIA Silver, $20/50%, 50%, 50% after Tier 1 Rx deductible, without BlueCard

! OMNIA Gold HSA, $10/$40/$75/$75 after Tier 1 deductible, with BlueCard



!Bronze50 - 50% after deductible, $25/50% after deductible Rx

! with BlueCard ! without BlueCard

If additional space is needed, attach a separate sheet, signed and dated.

5. To the best of your knowledge:

a. Are any employees or dependents presently incapacitated? ! Yes ! No

b. Are any dependent children incapable of self-support due to a physical or mental disability? ! Yes ! No

Additional space to explain if items 1, 2 or 3 were answered “Yes”. Refer to the question number, and give details including names, where appropriate.

_______________________________________________________________________________________________________________________

6. Does the employer participate in an arrangement with a Professional Employer Organization? ! Yes ! No

(Refer to Advisory Bulletin 00-SEH-02 if you need information concerning what constitutes a Professional Employer Organization.)

1. Is there any Group Health Plan:

• now in force and to be continued? ! Yes ! No

• currently being applied for? ! Yes ! No

If “Yes”, identify the name of the Group Health Plan, give a description of the plan(s) and name of insurance carrier(s):_______________________

__________________________________________________________________________________________________________________________

2. Name of present or prior group carrier: _________________________________________________________________________________________

Effective date of prior coverage: __________________________________ Cancellation/termination date: __________________________________

Is the coverage applied for in this application replacing other group insurance? ! Yes ! No

If “Yes”, give reason _________________________________________________________________________________________________________

Plan being replaced: ________________________________________________________________________________________________________

3. Are extended benefits provided in case of termination of health benefits? ! Yes ! No

4. To the best of your knowledge are there any current or former employees or their eligible dependents whose health insurance

is being continued? ! Yes ! No

Please provide the following information for each current/former employee or dependent on health continuations.

SECTION III: ALL QUESTIONS MUST BE ANSWERED

Name of

Employee/Dependent

Date of

Birth

Type of Continuation

State/Federal/

Extended Benefits

Reason for Termination

Disability/Other

Continuation Dates

Start End

32327 (1020)

Agent Producer Information (This information must be answered completely)

____________________________________________________ _______________________________ _________________________

BROKER SIGNATURE DATE VENDOR NUMBER

________________________________________________________________________________________________________________________________

BROKER-NAME NAME OF AGENCY TELEPHONE NUMBER

________________________________________________________________________________________________________________________________

STREET CITY STATE ZIP CODE

SECTION IV: AGENT/PRODUCER INFORMATION AND UNDERWRITING GROUP ENROLLMENT USE

SUB-PRODUCER INFORMATION AND COMMISSION SPLIT

Sub-Producer Information (This information must be answered completely)

__________________________________________________________________________________________________

SUB-PRODUCER SIGNATURE DATE NPN NUMBER

___________________________________________________________________________________________________

SUB-PRODUCER NAME NAME OF AGENCY TELEPHONE NUMBER

_________________________________________________________________________________________________

STREET CITY STATE ZIP CODE

_________________________________________%

Sub-Producer Commission Percentage

__________________________________________________________________________________________________

SUB-PRODUCER SIGNATURE DATE NPN NUMBER

___________________________________________________________________________________________________

SUB-PRODUCER NAME NAME OF AGENCY TELEPHONE NUMBER

_________________________________________________________________________________________________

STREET CITY STATE ZIP CODE

_________________________________________%

Sub-Producer Commission Percentage

__________________________________________________________________________________________________

SUB-PRODUCER SIGNATURE DATE NPN NUMBER

___________________________________________________________________________________________________

SUB-PRODUCER NAME NAME OF AGENCY TELEPHONE NUMBER

_________________________________________________________________________________________________

STREET CITY STATE ZIP CODE

_________________________________________%

Sub-Producer Commission Percentage

__________________________________________________________________________________________________

SUB-PRODUCER SIGNATURE DATE NPN NUMBER

___________________________________________________________________________________________________

SUB-PRODUCER NAME NAME OF AGENCY TELEPHONE NUMBER

_________________________________________________________________________________________________

STREET CITY STATE ZIP CODE

_________________________________________%

Sub-Producer Commission Percentage

SPECIAL INSTRUCTIONS

___________________________________________________________________________________________________

________________________________________________________________________________________

___________

___________________________________________________________________________________________________

__________________________________________________________________________________________________

___________________________________________________________________________________________________

_________________________________________________________________________________________________

32327 (1020)

For Internal Underwriting Use

! Approved for __________________________________________________ Number of Subscribers _______________________________________

Declined

Underwritten By __________________________________________________ Date _____________________________________________________

ADV EPO

ADV DA OMNIA

HSA

ADV DA

HSA ADV

EPO

OMNIA HSA

OTHER

DENTAL SAPD

COVERAGE CODE c/o

TOTAL APPLICATIONS SUBMITTED

TRANSFER FROM

GROUP # __________________________

REFUSALS/WAIVERS

LISTING ATTACHED (IF APPLICABLE)

EMPLOYER CONTRIBUTION

EFFECTIVE DATE

FUTURE RATE RENEWAL DATE

APPROVED BY: _______________________________________________ _____________________

REVIEWER SIGNATURE DATE APPROVED

For Internal Group Enrollment Use

32327 (1020)

It is understood that, except as provided under applicable regulations, no individual shall become insured while not actively at work on a full-time basis,

and only full-time employees are eligible. (Refer to the definition on the New Jersey Employer Certification.) It is further understood that no agent has

power on behalf of Horizon Blue Cross Blue Shield of New Jersey to make or modify any request or application for insurance or to bind Horizon Blue

Cross Blue Shield of New Jersey by making any promise or representation or by giving or receiving any information.

It is further understood that no insurance will be effective unless and until the application is accepted in writing by Horizon Blue Cross Blue Shield of New

Jersey. Final rates will be based on enrollment data as of the Policy effective date. No contract of insurance is to be implied in any way on the basis of

the completion and/or submission of this application.

It is understood that I am responsible to provide Horizon Blue Cross Blue Shield of New Jersey with timely and accurate information regarding the

date of hire for new employees and that the requested effective date of coverage will properly apply any orientation period and waiting period

requirements applicable to my plan. It is further understood that any retroactive termination requests must be limited to those for which no premium

or contribution has been paid for the termination period by the employee or dependent whose coverage is to be retroactively terminated.

! Please read this statement and check to confirm. I confirm that I have received the Summary of Benefits and Coverage (SBC) documents

associated with the plan or plans I selected on this application. I confirm I will provide SBCs to plan participants and beneficiaries as required by

federal regulations and guidance related to the distribution of the SBC, including the requiring for timing and delivery.

Any person who includes any false or misleading information on an application for an insurance policy is subject t o criminal and civil penalties.

Dated at __________________________________ on __________________

____________________________________________________________ _______________________________________________________________

Print name of Officer, Partner or Proprietor Signature of Officer, Partner or Proprietor

____________________________________________________________

Witness to Signature

Note: If there are any modifications to the statements and answers given in this application (i.e., crossed out , whited-out, erased information), the

applicant must attest to the modifications by giving a complete signature in the margin near the modification

SECTION V: SIGNATURE

32327 (1020)

An Independent Licensee of the Blue Cross and Blue Shield Association

NEW JERSEY SMALL EMPLOYER CERTIFICATION

Legal Name and Address of Employer: _______________________________________________________________

Name

______________________________________________________________________________________________

Street City State ZIP

Group Policy Number or Group Number: _____________________________________________________________

(if a current customer)

For purposes of certification as a New Jersey Small Employer, an Employer is considered to be a Small Employer if

the Employer satisfies the definition set forth below.

Employee and Small Employer Definitions

The definition of Small Employer counts employees as defined below.

Employee means an employee of the Policyholder. An individual and his or her legal spouse when the business is

owned by the individual or by the individual and his or her legal spouse, partners in a partnership, sole proprietors, a

2-percent S corporation shareholder and independent contractors are not employees of the Policyholder.

Small Employer means in connection with a Group Health Plan with respect to a Calendar Year and a Plan Year,

an employer who employed an average of at least 1 but not more than 50 employees on business days during the

preceding Calendar Year and who employs at least 1 employee on the first day of the Plan Year.

All persons treated as a single employer under subsection (b), (c), (m) or (o) of section 414 of the Internal Revenue

Code of 1986 shall be treated as one employer.

In the case of an employer which was not in existence throughout the preceding calendar year, the determination of

whether such employer is a small or large employer shall be based on the average number of employees that it is

reasonably expected such employer will employ on business days in the current calendar year.

The following calculation must be used to determine if an employer employs at least 1 but not more than

50 employees. For purposes of this calculation:

a) Employees working 30 or more hours per week are full-time employees and each full-time employee counts as 1;

b) Employees working fewer than 30 hours per week are part-time and counted as the sum of the hours each

part-time employee works per week multiplied by 4 and the product divided by 120 and rounded down to the

nearest whole number.

Add the number of full-time employees to the number that results from the part-time employee calculation. If the

sum is at least 1 but not more than 50 the employer employs at least 1 but not more than 50 employees.

Please note: Small Employer includes an employer that employs more than 50 full-time employees if the employer’s

workforce exceeds 50 full-time employees for no more than 120 days during the calendar year and the Employees in

excess of 50 who were employed during such 120-day or fewer period were seasonal workers.

Full-Time Employee Definition

The definition of Full-time Employee is used to determine eligibility for coverage under a small employer plan.

Full-time employees are counted when determining participation for a small employer.

Full-Time Employee means an employee who works a normal work week of 25 or more hours. Work must be at the

Policyholder's regular place of business or at another place to which an employee must travel to perform his or her

regular duties for his or her full and normal work hours.

Please note that the above definition of Small Employer above considers full-time to be 30 hours per week and

that definition of full-time is used solely for determining whether an employer is a Small Employer. For purposes

of determining which employees are eligible for insurance under a Small Employer plan and whether the Small

Employer meets the participation requirement, full-time is defined as 25 hours per week.

32285 (0119)

Please indicate below the number of employees by work location/State. Refer to the definition of “employee” on page 1.

All employees must be included, regardless of whether or not they currently have medical coverage and through whom

that coverage is provided.

Number of Employees or Former Employees

The following information will be used to calculate the participation rate. Refer to the definition of “full-time employee”

on page 1 that counts employees working 25 or more hours per week.

Total # Full-time Employees _________

Total # Full-time Employees applying/enrolling for health benefits coverage _________

Total # Full-time employees waiving health benefits coverage under the policy with coverage under their spouse's or

parent’s group coverage, Medicare, Medicaid, or NJ FamilyCare or Tricare or any other group Health Benefits Plan

through a different employer _________

Total # Full-time employees waiving health benefits coverage under the policy with coverage under a Health Benefits

Plan issued by another carrier and offered by the small employer: _________

Please separately list the name(s) of the other carrier(s) and the number of employees covered under each:

_____________________________________________________________________________ _________

Total # Full-time employees waiving health benefits coverage under the policy without coverage under a spouse's or

parent’s group coverage; Medicare, Medicaid, or NJ FamilyCare or Tricare or any other Health Benefits Plan _________

Total # Employees in an ineligible class or classes _________

The following information will be used to determine how certain federal laws apply to the Small Employer.

Is your firm subject to Working Aged Provisions of federal law (TEFRA/DEFRA)?  Yes  No

(You may be subject to the law if you employed 20 or more employees for 20 weeks in the current or prior calendar year)

If yes, provide the number of full-time and part-time employees you employed for at least 20 or more weeks in the

current or prior calendar year. _____________

For purposes of this question “employee” includes: full-time employees, part-time employees, seasonal employees,

temporary employees, employees who are union members, owners, partners, officers and excludes self-employed

persons, independent contractors (1099), directors

Is your firm subject to the requirements of the federal COBRA law?  Yes  No

(You may be subject to the law if you employed 20 or more employees during 50% or more of the working days during

the previous calendar year.)

For purposes of this question “employee” includes: full-time employees, part-time employees, seasonal employees,

temporary employees, employees who are union members, owners, partners, officers and excludes self-employed

persons, independent contractors (1099), directors.

If yes, provide the number of full-time and part-time employees you employed during 50% or more of the working

days during the previous calendar year. _____________

Each part-time employee counts as a fraction of an employee, with the fraction equal to the number of hours the

part-time employee worked divided by the hours an employee must work to be considered full-time.

Work Location (list by State)

Full-time

Part-time

COBRA or

State

Continuees

Other

32285 (0119)

 I certify that I qualify as a Small Employer in the State of New Jersey.)

AND

 I certify that the information provided to Horizon Blue Cross Blue Shield of New Jersey is true and complete. I

understand that if the above information is not complete or is not provided to Horizon BCBSNJ, in a timely manner,

then health benefits coverage does not have to be offered or continued. I further understand that incomplete or

untrue information may void health benefits coverage.

 I certify that I have obtained and maintain a stand-alone pediatric dental plan for all employees and dependents

enrolling for health benefits coverage.

_______________________________________________________________________________________________________________

Signature of Officer, Partner or Owner Title

_______________________________________________________________________________________________________________

Print Name of Officer, Partner or Proprietor Date

_______________________________________________________________________________________________________________

Signature of Witness Date



I certify that I am NOT a Small Employer in the State of New Jersey, as defined above.

_______________________________________________________________________________________________________________

Signature of Officer, Partner or Proprietor Title

_______________________________________________________________________________________________________________

Print Name of Officer, Partner or Proprietor Date

_______________________________________________________________________________________________________________

Signature of Witness Date

Any person who includes any false or misleading information on an application or enrollment form or

certification for a health benefits plan is subject to criminal and civil penalties.

CERTIFICATION AS A SMALL EMPLOYER IN THE STATE OF NEW JERSEY

For a Group Health Benefits Plan

Please sign and date appropriate section indicating whether or not you meet the definition of a small employer .

32285 (0119)

Name

Job Title

Date of

Employment

Hours

Worked

Per Week

Status

Work Location

(State)

Date of Birth

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

*If additional space is needed, attach a separate sheet.

Complete this section if you have certified that the Employer is a Small Employer

*CENSUS INFORMATION

Please include the following persons in the following list:

a. employees, owners, partners, and officers who are actively working for the employer on a regular basis, and are paid

by the employer on a regular basis, whether or not they are eligible to be covered under the policy.

b. employees, owners, partners and officers who are not working, but who are currently covered under the employer's

health benefits plan for reasons such as continuation of coverage or total disability.

Please use the following letters to indicate Status:

O: Owner, partner or officer

F: Full-time employee who works 25 or more hours per week

P: Part-time employee who works less than 25 hours per week

S: Seasonal employee (employee works 120 days or fewer per year)

D: Totally Disabled employee

C: Continuee under state or federal law

U: Employee participating in an employee welfare arrangement established pursuant to a collective bargaining agreement.

32285 (

0119)

Group Policy No.: ____________________________

Policyholder Name: _______________________________________________________________________________________

Employee Name: _________________________________________________________________________________________

Last First MI

Marital Status:  Single  Married  Widowed  Divorced

Date of Employment: ____________________________________ Date of Birth: _____________________________________

I was given the opportunity to enroll in this plan of group health benefits offered by my employer and insured by Horizon

Blue Cross Blue Shield of New Jersey. I refuse the following:

 Employee, Spouse and Child(ren) coverage

 Spouse coverage

 Child(ren) coverage

Reason for Refusal (Please check all appropriate boxes.)

 other fully-insured Group Health Plan sponsored by this employer

 other Group Health Plan sponsored by my spouse’s employer

 other group coverage sponsored by another organization

 covered under Medicare

 other reasons (please explain) ______________________________________________________________________

Please identify Group Health Plan(s) and provide names(s) of policyholder(s), carrier(s) and policy number(s).

Policyholder/Name: _____________________________________ ___________________________________ ________

Last First MI

Carrier: _____________________________________________________ Policy Number: ________________________

Policyholder/Name: _____________________________________ ___________________________________ ________

Last First MI

Carrier: _____________________________________________________ Policy Number: ________________________

Policyholder/Name: _____________________________________ ___________________________________ ________

Last First MI

Carrier: _____________________________________________________ Policy Number: ________________________

If you are declining enrollment for yourself or your dependents (including your spouse) because of other Group Health Plan coverage,

you may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 90 days after

your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption,

you may be able to enroll yourself and your dependents provided that you request enrollment within 30 days after marriage, birth,

adoption or placement for adoption.

I understand that if I later wish to enroll for any of the coverage(s) refused, I will be required to submit an Enrollment Form.

____________________________________________________________________________ Date: _____ / _____ / ________

Signature of Employee MM DD YYYY

____________________________________________________________________________ Date: _____ / _____ / ________

Signature of Witness MM DD YYYY

An Independent Licensee of the Blue Cross and Blue Shield Association

SMALL EMPLOYER HEALTH BENEFITS WAIVER OF COVERAGE

32286 (0119)

APPLICATION FOR VISION BENEFITS

THROUGH A SMALL EMPLOYER HEALTH PLUS PLAN

Horizon Insurance Company is the affiliate company for Vision benefits.

Please print or type

___ New Policy ___ Change in Policy Policy No. _____ Requested Effective Date

___________

SECTION I: POLICYHOLDER INFORMATION

Policyholder (full legal name of company): _________________________________________________________

____

Tax Identification Number: _________________________________________________________________

_________

Main Address: _______________________________________________________________________

____________

ZIP

Street City State

Mailing Address

(Billing): __________________________________________________________________

Street City State ZIP

SECTION II: SPECIFICATIONS FOR COVERAGE

Select one of the following:

Low package option

Horizon Vista II

High package option

Horizon Panorama IV

SECTION III: SIGNATURE

It is understood that no individual shall become insured while not actively at work on a full-time basis, and only full-time

employees are eligible. A full-time employee is one who regularly works at least 25 hours per week at his employer’s

place of business. It is further understood that no agent has power on behalf of Horizon Blue Cross Blue Shield of New

Jersey to make or modify any request or application for insurance or to bind Horizon Insurance Company on behalf of

Horizon Blue Cross Blue Shield of New Jersey, Inc. by making any promise or representation or by giving or receiving

any information.

It is further understood that no insurance will be effective unless and until the application is accepted in writing by

Horizon Blue Cross Blue Shield of New Jersey, Inc. No contract of insurance is

to be implied in any way on the basis of

the completion and or submission of this application. Any person who knowingly files a statement of claim, application

for insurance, enrollment form, or certification containing any false or misleading information may be subject to criminal

and civil penalties.

___________________________________________

Print name of Officer, Partner, or Owner

___________________________________________

Signature of Officer, Partner, or Owner

___________________________________________________ Dated at _________ on _____________________

Witness to Signature

Note: If there are any modifications to the statements and answers given in this application (i.e., crossed out, whited-

out, erased information), the applicant must attest to the modifications by giving a complete signature in the margin near

the modification.

Services and products may be provided by Horizon Blue Cross Blue Shield of New Jersey, Horizon Healthcare of New Jersey, Inc., and products and policies may be provided by Horizon

Insurance Company, each of which is an independent licensee of the Blue Cross and Blue Shield Association. Communications are issued by Horizon Blue Cross Blue Shield of New Jersey

in its capacity as administrator of programs and provider relations for all its companies. The Blue Cross® and Blue Shield® names and symbols are registered marks of the Blue Cross and

Three Penn Plaza East, Newark, New Jersey 07105-2200

32335 (W0918)

AGENT/PRODUCER INFORMATION (THIS INFORMATION MUST BE ANSWERED COMPLETELY)

BROKER SIGNATURE

DATE

VENDOR NUMBER

BROKER-NAME

NAME OF AGENCY

TELEPHONE NUMBER

STREET CITY STATE

ZIP CODE

OTHERS (NAME,

TITLE)

SPECIAL INSTRUCTIONS

FOR INTERNAL GROUP VISION USE

Coverage Code

TOTAL APPLICATIONS SUBMITTED

TRANSFER

FROM

GROUP #

EMPLOYER CONTRIBUTION

EFFECTIVE DATE

FUTURE RATE RENEWAL DATE

SALES ASSOCIATE SIGNATURE

DATE

ITEM NUMBER

APPROVED BY: SALES ADMINISTRATION SIGNATURE

TITLE DATE

32335 (W0918)

ICC21-SG2-APP (3-21)

21L-USAL-0737

1 NJ – Menu Plans (Rev. 6-21)

P.O. Box 1650

Little Rock, Arkansas 72203

SMALL GROUP INSURANCE APPLICATION (GIIM)

Type or Print in Black Ink

SECTION I. GROUP INFORMATION:

1. Legal Name of Policyholder:

2. Taxpayer ID#:

3. Effective Date of Coverage:

4. Type of Company: ❑ Corporation ❑ LLC ❑ PC ❑ S-Corp ❑ Sole Proprietor ❑ Partnership ❑ Government ❑ Other __________

5. Nature of Business

6. SIC Code

7. Name of Subsidiary or Affiliate Companies to be Covered

8. SIC Code/Affiliate

9. Mailing Address of Policyholder

City

State

Zip+4

10. Contact Information at Company:

❑ Benefits or ❑ Billing Contact Person ________________________________________________________________________________

Phone/Fax Number ( ) ______________________ E-mail Address _____________________ Web Address _______________________

11. Class Definitions. Small Group is limited to three classes with a minimum of 2 employees/class. Voluntary plans are limited to one class.

Class

Life

LTD

Grp.

Vol.

Description of Class

Waiting Period, if Different

❑

12. Do you have any employees located in states other than the Policyholder’s main

address? (if yes, please indicate states below)

❑ Yes ❑ No States:______________________________________________

13. Billing Method:

❑ Self-Administered

❑ Online Billing ❑ List Bill

14. Total number of eligible employees:

Group: ________ Voluntary: ________

15. Total number of employees enrolled:

Group: ________ Voluntary: ________

16. Employer contribution:

Group: ________ Voluntary: ________

17. Do you allow Domestic Partner Coverage under the existing Medical Plan? ❑ Yes ❑ No

18. Waiting Period: ❑ First of the following month after completion of __________ days, or

❑ Day following Hire Date (VLTD requires a 30 day minimum waiting period.)

19. Minimum hours per week:

Group: ______ Voluntary:________

20. Eligible Waiting Period Applies to: ❑ Future Employees Only ❑ Present & Future Employees

Does the waiting period apply to employees rehired within 12 months of their termination date ❑ Yes ❑ No

20a. Annual Enrollment date for

Voluntary Coverage: ________

21. Replacement: Are any of the following a replacement of similar coverage? If prior coverage, please include a copy of the prior carrier’s plan.

Yes

Grp.

Vol.

Coverage

If Yes, Previous Carrier

Termination Date

❑

Life & AD&D Insurance

❑

Long Term Disability

SECTION II. EMPLOYER BENEFIT OPTIONS: FOR GROUPS WITH 2 TO 50 ELIGIBLE EMPLOYEES

SELECT COVERAGES THAT BEST MEET THE GROUP’S NEEDS. Term Life/AD&D is required for LTD purchase.

STEP 1: Select the Life/AD&D and LTD Coverage for the Employees and the Class Applicable for that Amount

Group Term Life and AD&D Insurance

Group Long Term Disability

Choice

Class

(Circle one)

No. of

ee’s

Term Life and

AD&D Benefit

Choice

Class

(Circle one)

No. of

ee’s

LTD

Benefit

Duration

5 YR RBD

65 RBD

❑

1, 2, 3

_____

$25,000

❑

1, 2, 3

_____

$500

❑

N/A

❑

1, 2, 3

_____

$35,000

❑

1, 2, 3

_____

$1,000

❑

N/A

❑

1, 2, 3

_____

$40,000*

❑

1, 2, 3

_____

$1,500*

❑

1, 2, 3

_____

$50,000*

❑

1, 2, 3

_____

$2,000*

❑

N/A

*Requires a minimum of 5 eligible employees participating. Amounts between classes may not exceed 2x the lower amount.

All active full time employees enrolled in the Small Employer Health Plus Plan

N/A

100

■

P.O. Box 1650

Little Rock, Arkansas 72203

SMALL GROUP INSURANCE APPLICATION (GIIM)

Type or Print in Black Ink

ICC21-SG2-APP (3-21)

21L-USAL-0714

2 NJ – Menu Plans (Rev. 6-21)

STEP 2: Select Enhancements to the Group Coverages

Dependent Life Coverage: Spouse/child: $5,000/$2,000 (Child

coverage from 14 days to 6 months is limited to $100)

SECTION III. EMPLOYEE BENEFIT OPTIONS (VOLUNTARY PLANS): FOR GROUPS WITH 10 TO 50 ELIGIBLE EMPLOYEES

Instructions: Group must elect Group Term Life/AD&D if VGTL/VAD&D or VLTD is desired. The employer cannot offer both group LTD and

voluntary LTD.

❑ Voluntary* Term Life & AD&D

Benefits

Employee (Life & AD&D)

Available amounts from $20,000 to $50,000 in $10,000 increments

Dependent (Life only - spouse/child)

Available amounts of $10,000/$5,000 or $20,000/$10,000

❑ Voluntary* LTD

❑ 5 yr RBD or ❑ To Age 65 RBD

The employer elects duration and one

monthly benefit amount for all employees.

The employee elects to purchase.

Available Monthly Benefit Amounts

❑ $500; ❑ $750; ❑ $1,000; ❑ $1,500

*All voluntary plans require a minimum of 10 eligible employees, with a minimum of 5 participating or 25%, whichever is greater

TERM LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT FEATURES:

Group and Voluntary AD&D Riders

Benefits reduce by the following amounts on the insured’s birthday*

Group & Voluntary Plans

Voluntary Plans

Reduction at Age of Employee

Seat Belt /Air Bag/Helmet

Special Education

Age 65

Age 70

Coma

Spouse Training

35%

50%

Repatriation

* Benefits for the covered person(s) terminate when no longer eligible or at

retirement, whichever comes first.

Exposure and Disappearance

LONG TERM DISABILITY FEATURES:

Disability Definition: Earnings / Occupation Test (80/20); 24 month own occupation

Drug & Mental Illness Limitation: 24 Month Lifetime Benefits

Elimination Period: 180 Days (Group & Voluntary)

Benefit Percentage: Flat benefit not to exceed 60% of pre-disability earnings

Pre-existing Condition: Group LTD: 3/12; Voluntary LTD: 12/6/24

Integration: non-integrated; Voluntary amounts above $1,000 are integrated.

W-2 Service Options for Long Term Disability

❑ Option 1: Withhold Federal income Taxes and the employee’s portion of FICA. Prepare and File W-2 Forms.

❑ Option 2: Withhold Federal income Taxes and the employee’s portion of FICA. Policyholder waives W-2 Forms Services.

A detailed description of the W-2 services elected by the Policyholder pursuant to this application will be sent to the Policyholder by mail. Such services

will be performed in accordance with the above election and established standard procedures.

SECTION III. AUTHORIZATION

REMARKS OR SPECIAL PROVISIONS:

The undersigned employer and /or authorized representative hereby request that it be approved for insurance coverage through USAble Life and agrees

to comply with all terms and provisions of the Group Policy(ies) issued in response to this application.

It is understood and agreed that this application shall be made a part of the policy or policies applied for and that no insurance shall be effective until

approved by USAble Life.

This application is governed by the laws of the state of New Jersey.

Warning: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties

under state law.

____________________________________

Dated at (City & State)

__________________________

Date

______________________________________________

Signature of Policyholder and Title

___________________________________

Name of Licensed Agent

_____________________________

Signature of Licensed Agent

For Home Office Use Only

Group #

■

BEN-DESIG (2-16) Page 1 of 2

P.O. Box 1650

Little Rock, Arkansas 72203-1650

Beneficiary Designation Form

Date Received Home Office

Insured Name (First, MI, Last)

Birthdate

Social Security Number

Address Street City State ZIP

Daytime Telephone

( )

Employer Name (if applicable)

Policy Number

I hereby designate the following beneficiary(ies):

PRIMARY BENEFICIARY(IES) - Will receive proceeds if living at death of Insured:

Last Name

First Name

Social

Security #

Birthdate

Relationship

Percentage

Total =

(Total must

equal 100%)

CONTINGENT BENEFICIARY(IES) - Will receive proceeds if Primary Beneficiary(ies) are also deceased

at death of Insured:

Last Name

First Name

Social

Security #

Birthdate

Relationship

Percentage

Total =

(Total must

equal 100%)

Dated at _________________________ , this the _____ day of __________________ , _____________ .

Signature of Insured

Signature of Policyowner (if other than Insured)

THIS BENEFICIARY DESIGNATION IS NOT VALID UNTIL RECEIVED AND ACCEPTED BY YOUR EMPLOYER’S

HOME OFFICE.

See Page 2/Reverse Side For Instructions

BEN-DESIG (2-16) Page 2 of 2

INSTRUCTIONS

1. The signature of the Insured and Policyowner (if other than Insured), is required.

2. This form must be completed, signed, and forwarded to Your Employer’s Home Office.

3. Give full legal name of each beneficiary and relationship to the Insured.

SAMPLE BENEFICIARY DESIGNATIONS

1. UNNAMED CHILDREN AS BENEFICIARIES: The legal, natural or adopted child or children

of the Insured.

2. PARTNERSHIP AS BENEFICIARY: Doe & Company, 100 North Main, Anytown, USA, a

partnership composed of John H. Doe and Richard A. Doe.

3. CORPORATION AS BENEFICIARY: Doe & Company, 100 North Main, Anytown, USA, a

corporation organized under the laws of the State of Arkansas.

4. TRUST AS BENEFICIARY: John H. Doe, Trustee under Trust Agreement dated ______,

______.

5. CHARITY: American Cancer Society, 234 Main, Anytown, USA.