(for office use only)
Company Information
Company Name(the name provided will be used on your monthly invoice and is limited to 30 characters): / Effective Date:
Street Address:CityStateZip / Business Nature:
NAICS: SIC:
Employer Tax ID (EIN)#: / Corp. Proprietor
Partnership Other / Membership: Associated Industries GVCC
Effective Date: Expiration Date:
Executive Contact Name (President, Owner, CEO, Etc.) / Email:
Phone: () - Fax: () -
Group Benefits Administrator: / Email:
Phone: () - Fax: () -
Billing Representative:
Billing Address: / Email:
Phone: () - Fax: () -
Is your company headquartered in Washington? Yes No
If No, please indicate headquartered State: / Do you employ at least one common law employee: Yes No (Defined as an individual whose work is directed by somebody else)
Medical Product Selections – All Medical plans are creditable with the exception of the Ascent HSA 5000 Plan
Compulsory benefits with Medical include $15,000 Basic Life and AD&D coverage DECLINE MEDICAL
Medical and Prescription Drug Plans Underwritten by Regence BlueShield
Pinnacle Plan Options:
RX $10/$30/$50 / Traverse Plan Options: RX $10/$40/$60 / Ascent Plan Options:
RX $10/$40/$60/50% / ActiveCare 2500
Pinnacle 250 / Traverse 500 / Traverse 2500 / Ascent 3000 / MultiCare
Pinnacle 500 / Traverse 750 / Traverse 2750** / Ascent 5000 / UW Medicine
Pinnacle 1000 / Traverse 1000 / Traverse 1500 HSA* / Ascent 5000 HSA* / The Everett Clinic
Pinnacle 1500 / Traverse 1500 / Traverse 2500 HSA* / EvergreenHealth
Traverse 2000 / *HSA RX is covered at 80% and deductible applies
**RX for this plan only is $10/$40/$100 / Partners/Overlake
NOTE: If an HSA Plan is selected, please indicate the employer contribution percentage (0% - 100%) % of the deductible to the HSA Fund. If an HSA plan is selected, the group has the option to utilize HealthEquity Eligibility integration. Do you want Health Equity to administer your HSA? Yes No
If Yes, who will be paying the monthly fee: Employer Employee If No, which bank will be utilized
Non-Medical Product Selections - Please check decline box if declining coverage
Life and Disability OptionsUnderwritten by TheStandard DECLINE ADDITIONAL LIFE/AD&D
$15,000 (included as a compulsory benefit when purchasing medical)
$30,000 (additional $15,000) $50,000 (additional $35,000)
1xBase Annual Earning (BAE) (+ $15,000) 2xBAE (+ $15,000)
Voluntary Life/AD&D –Employee & Spouse (no separate voluntary AD&D permitted)$10,000 Child LifeShort-Term Disability Options DECLINE STD
Option 1 Option 2 Option 3
STD 60% to $750/week max STD 60% to $2500/week max STD 60% to $1250/week max
Long-Term Disability Options DECLINE LTD
Option A60% to $3000/month max Option 160% to $4000/month max Option 260% to $8000/monthmaxDental Plans Underwritten by Delta Dental of Washington DECLINE DENTAL
$1,000 PPO Provider 00155-1 (enrolled prior to July 2013) $2,000 PPO Provider 00155-2(enrolled prior to July 2013)$1,000 PPO Incentive 00154-1 $2,000 PPO Incentive 00154-2
$1,000 PPO Provider 00156-1 $2,000 PPO Provider 00156-2
Orthodontia Adults and Dependent Children Option Orthodontia Dependent Children Only Option
Rating Option (Groups Prior to January 2007 Only) All new groups will have tiered rating.
Tiered for groups >25 Composite for groups >25 Composite for groups of <24
Vision Plan Underwritten by VSP Vision Care, Inc. DECLINE VISION
Choice Plan A Signature Plan B
/ Magellan EAP Yes NoRATES
Employee: / Emp/Sp: / Emp/Sp/Child(ren): / Emp/Child(ren):
Medical Plan 1: / $ / $ / $ / $
Medical Plan 2: / $ / $ / $ / $
Medical Plan 3: / $ / $ / $ / $
Dental Plan: / $ / $ / $ / $
Ortho Rates: / $ / $ / $ / $
Vision Plan: / $ / $ / $ / $
Basic Life/AD&D: / $ / $ / $ / $
Dependent Life: / $ / N/A / N/A / N/A
STD: / $ / N/A / N/A / N/A
LTD: / $ / N/A / N/A / N/A
EAP: / $PEPM / N/A / N/A / N/A
Eligibility and Participation Requirements
Definition of Eligible Employee: Eligible Employees must be regular (not seasonal or temporary) active employees on company payroll working a minimum of 20 hours per week to be eligible for coverage. Per regulation guidelines, all employees working at least 30 hours per week are eligible for benefits.
All full-time Employees working a minimum of hours per week (not less than 20)
All part-time Employees working a minimum of hours per week (not less than 20)
Orientation/Waiting Period Information:Coverage for newly hired/eligible employees will become effective the first
of the month following the completion of the orientation and/or waiting period.
Prior to the waiting period, a one monthOrientationPeriod will be applied: YES NO
Waiting Period is effective the first of the month following: Date of Hire 30 days 60 days
Eligibility and Participation Requirements(Continued)
Waive Waiting/Introductory Period: New groups only
For employees transferring from part-time to full-time status, the waiting period above should applyRetroactive to the original date of hire
Beginning at the date of transfer
Employer Contribution and Employee Participation Requirements: The employer must contribute the minimum percentages shown below toward the cost of coverage and must meet the minimum participation requirements. Minimum Contribution/Participation Requirements:50% Employer Contribution- 75% Employee Participation or 100% Employer Contribution- 100% Employee Participation
Medical
Employee:% $ Flat Amount (must equal 50% or more of medical and Rx premium)Dependent:% $ Flat Amount (must equal 50% or more of medical and Rx premium)
Dental
Employee:%Dependent:%
Employee Enrollment- CLASSING OUT EMPLOYEES AS INELIGIBLE IS NOT ALLOWED
Class Description (Only groups of ten or more employees may have different classifications and must not be discriminatory)Class 1:______Waiting Period :______
Medical Dental
Employee: % %
Dependent: % % / Class Description (Only groups of ten or more employees may have different classifications and must not be discriminatory)
Class 2:______Waiting Period :______
Medical Dental
Employee: % %
Dependent: % %
Total number of employees on payroll regardless of hours worked: (A)
Employees not eligible to enroll:
Working less than the min. hrs:
Temporary or seasonal:+
In probationary period:+
= (B) / Employees not enrolling due to coverage under:
Medicare, CHAMPUS/Tricare, Military:
Other group coverage +
Union += (C)
Eligible Out of state employees Yes No
Number enrolling
Total number of eligible employees (A)-(B)-(C) = (D)
Eligible employees waiving enrollment without other coverage: (E)Total number of eligible employees enrolling (D)-(E)=
Current Medical Plan Information (New Groups Only)
Is this plan intended to replace any existing coverage? Yes No
If yes, complete the following:
Name of prior medical carrierOriginal Effective Date: Term Date:Name of prior dental carrierOriginal Effective Date: Term Date:
Deductible and out of pocket amounts accumulated on a: calendar year (accumulates January through December)
plan year (accumulation matches contract renewal period)
COBRA/TEFRA/OBRA/FMLA Designation
We strongly urge you to consult with legal counsel in answering the following questions. The summaries below are not intended to be, nor may they replace legal advice regarding any employer’s legal obligations. Further, it is the employer/group’s responsibility to inform the carrier immediately if facts change that cause the group’s answers below to change.
COBRA
Please note: ALL medical groups are COBRA eligible / All groups are eligible for COBRA through the Trust. This service is provided at no cost. As a group enrolled in this Trust, your employees are entitled to COBRA benefits. AIMS will manage the COBRA Administration for these benefits.
FMLA Employer / Yes
No / Helpful Hint: Generally, these federal and state laws apply to any employer that employed at least 50 employees each working day during at least 20 weeks in the current or preceding year. The term employee includes full-time, part-time, temporary or joint employees, as well as those acquired through succession are to be counted.
TEFRA/OBRA / I agree / TEFRA and OBRA eligibility will be assumed for all participating member companies regardless of size; however it will be the responsibility of the member to inform Medicare of their status so that claims will be properly adjudicated.
Adoption of Trust Agreement, Appointment of Trustee & Understanding of the Terms of Selection and Participation
The employer does hereby adopt the Trust Agreement and agrees to abide by its terms and designates and appoints the undersigned Group Representative as a Trustee of the Trust, unless otherwise specified in the Trust Agreement.
The undersigned Employer understands that any change to the selections made on the Master Application for Health and Other Insurance Coverage shall occur only at the renewal date and are subject to approval. The undersigned Group Representative understands that an exception to this would be iffederal,state,orlocalauthoritiesmandate materialbenefit,eligibility,procedure,ortaxchanges.
The undersigned Employer acknowledges the receipt of the Group Administrative Guide and agrees at all times to adhere to the established rules and procedures as set forth in the Group Administrative Guide including, but not limited to the terms, conditions and limitations described in the initial Underwriting and Administrative Guidelines, billing and administrative guidelines, and other applicable administrative guidelines. The undersigned Employer understands that it is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines and denial of insurance benefits. The undersigned employer understands that information collected in connection with administration of this benefit plan may be used to bring to attention health products or services that might be valuable to all qualified employees. The employer recognizes the employee’s authorization to deduct from their earnings the amount, if any, for the coverage selected.
The undersigned Employer acknowledges and agrees that once its application has been approved and accepted, any request to rescind its application must be made in writing and must be received no later than the close of business on the last business day at least 48 hours before the effective date of coverage. If a proper request to rescind is not received timely, premiums will not be refunded and the coverage will be in effect as approved and accepted.
FRAUD STATEMENT:
I have provided these answers as part of the application procedure required by RBS/ANH to enroll in coverage and I certify that all information completed on this form is true, correct, and complete. I understand that RBS/ANH will rely on each answer in making coverage and rating determinations. If RBS/ANH continues the Contract with the Group after untrue, incorrect, or incomplete information is found to have been provided, and if as a result of correcting false information the Group no longer qualifies for the Rate quoted, I understand that RBS/ANH has the right to adjust the rates during the term of the plan year and prior to renewal.
Any person who knowingly and with intent to defraud any health carrier, insurance company or other person files an application for health coverage or insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. It is a crime to knowingly provide false, incomplete, or misleading information to a health carrier or insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, and denial of health coverage or other insurance benefits.
Third Party Administrator:
The undersigned Employer agrees that AIMS shall act as a third party administrator (TPA) for the Trust and/or the Plans, and that it may provide or select service providers to provide any of the duties in Sections 6.10 or 7.01 of the Trust Agreement.
Administrator and Named Fiduciary:
The undersigned Employer agrees that the Administrator and Named Fiduciary of the Plans provided through the Trust shall be Trustees and the Administrator and Named Fiduciary shall have the authority to control and manage the operation and administration of the Plans as described in the trust agreement.
Premium:
The undersigned Employer acknowledges and agrees that full payment of premium to AIMS is due on the first day of the month for which coverage is purchased, that any payment of premium received by AIMS after the 10th day of the month is lateas established in the Underwriting and Administrative Guide and subject to the late fee.Any premium received by AIMS more than 20 days after the due date will be returned to the undersigned Employer and the Employer’s group insurance coverage will be terminated as of the last day of the last month for which full payment was timely received. Participation in the Trust may be limited to Employers that participate in certain associations or industry groups.
Signature Section and Group Agreement to Contract
You, the producer(s), certify that you have met with the group submitting this agreement and that you have fully explained its contents. You have discussed coverage, eligibility, any pre-existing condition waiting periods, the effect of misrepresentations, termination provisions and subscription charge billing administration.
**ALL FIELDS REQUIRED FOR COMMISSION PAYMENT SET UP**
Accredited Producer Signature / Date
Accredited Producer of Record (Print Name) / Name of Firm/Agency
Firm/Agency Mailing Address / Accredited Producer Phone Number () -
Accredited Producer E-mail Address / Accredited Producer Fax Number
Producer Account Manager / Account Manager Email
Legal Name for Commissions and 1099 / Agency/Producer Tax-ID #
I certify that the information on this agreement is complete and accurate. I also agree to be bound by the terms, conditions, and provisions of coverage as set forth by the Trust and carriers’ plan booklets and contracts. With my signature, I also hereby appoint the above named producer as our company’s producer of record.
I understand there is no coverage in effect until this Application is accepted, premium is deposited, and an effective date of coverage is established. I understand that this coverage is subject to Legislative mandates and changes. Final rates are subject to the execution of the Group MasterApplication. If this Application is not accepted, the premium deposit will be refunded. THE PARTICIPATING EMPLOYER UNDERSTANDS AND AGREES THAT THE EMPLOYER SHOULD KEEP PRIOR COVERAGE IN FORCE UNTIL NOTIFIED OF ACCEPTANCE IN WRITING. IT IS UNDERSTOOD AND AGREED THAT NO PRODUCER HAS THE AUTHORITY TO: a. modify this Application; b. waive the answer to any question; c. bind the Trust or the carrier in any way by giving or receiving any date which is not written on this Application; or d. bind the Trust or the carrier by making any promise or representation.
Electronic Disclosures: Please check here if you would like your employees to receive required disclosures electronically and you confirm that utilizing a computer and accessing email is an essential part of your employees’ work activity. I agree
Group Representative’s Signature / Date
Group Representative (Print Name) / Title
Receive Monthly Invoice Electronically? Yes No
Email Address: / Submit Monthly Premium via ACH? Yes No
(If yes, please attach completed ACH form)
Submission Checklists
Mail New Business to:
Attn: Associated Industries
1200 Fifth Avenue
Suite 1100
Seattle, WA 98101
Email to:
/ New Group Checklist:
Premium Check – Payable to: Business Industry Trust
ACH Form (if applicable)
Group Master Application (GMA)
Group HRQ Form
Late Submission Letter if submission is after the 15th
Copy of invoice from prior coverage
Employee Enrollment/Waiver Form
Association Membership Applicationand Payment, Payable to Association
Association Membership Expiration Date (if a current member)
Most current EOB for each enrollee to credit deductibles
Renewal Case Submission Checklist:
Group Master Application (GMA)
Association Membership expiration date
Submit by the 15th of month prior to the effective date of coverage
Plans Provided By:
Regence BlueShield / 1800 Ninth Avenue, Seattle WA 98101
The Standard / 920 SW 6th Avenue, Portland, OR 97204
Delta Dental of Washington / 400 Fairview Avenue North, Suite 800, Seattle, WA 98106
VSP, Vision Care Inc. / 3333 Quality Drive Rancho Cordova CA 95670
Magellan Health Services / 14100 Magellan Plaza Drive MO-10, Maryland Heights, MO 63043
Services & access provided by Associated Industries Management Services
8200A 2018 Business IndustryRBS Group Master Application12/18/2017
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For Office Use OnlyDate Received:
Medical Group Number:
Medical RL:
Dental Subgroup Number:
Services & access provided by Associated Industries Management Services
8200A 2018 Business IndustryRBS Group Master Application12/18/2017
1 of 6