ALL - Supplemental Health

ROSTER

Completed Pending N/A

WKLY CASES

Completed Pending N/A

BILLING

Completed Pending N/A

Get an Instant Supplemental Health Insurance Quote

EXCHANGE

Yes

Desired Coverage Effective Date*

CANNOT BACKDATE COVERAGE

Participating Organization

Get an Instant Supplemental Health Insurance Quote

Basic Plan

Coverage Amount	Monthly Rate
Enrollee Only	$14.99
Enrollee & Spouse or Domestic Partner	$26.38
Enrollee & Dependent Child(ren)	$27.57
Enrollee & Family	$37.59

Choice Plan

Coverage Amount	Monthly Rate
Enrollee Only	$24.99
Enrollee & Spouse or Domestic Partner	$43.98
Enrollee & Dependent Child(ren)	$45.96
Enrollee & Family	$62.67

Enhanced Plan

Coverage Amount	Monthly Rate
Enrollee Only	$34.99
Enrollee & Spouse or Domestic Partner	$61.58
Enrollee & Dependent Child(ren)	$64.35
Enrollee & Family	$87.75

Elite Plan

Coverage Amount	Monthly Rate
Enrollee Only	$49.99
Enrollee & Spouse or Domestic Partner	$87.98
Enrollee & Dependent Child(ren)	$91.94
Enrollee & Family	$125.37

Rates are subject to change.

Web Request Form & Electronic Signature Agreement

Consumer Disclosure Regarding Conducting business electronically, Receiving Electronic Notices and Disclosures, and Signing Documents Electronically
Please read the following information, by proceeding forward and signing this document you are agreeing that you have reviewed the following consumer disclosure information and consent to transact business using electronic communications, to receive notices and disclosures electronically, and to utilize electronic signatures in lieu of using paper documents. This electronic signature service is provided on behalf of Business Planning Concepts, Inc dba Member Benefits "sending party" herein referred to as "Member Benefits", the administrator, whom are sending electronic documents, notices, disclosures or requesting electronic signatures to you.

You are not required to receive notices and disclosures or sign documents electronically. If you prefer not to do so, you may request to receive paper copies and withdraw your consent at any time as described below.

Paper Copies
You are not required to receive notices or disclosures or sign documents electronically and may request paper copies of documents or disclosures if you prefer to do so. You also have the ability to download and print any open or signed documents sent to you through the electronic signature system. Member Benefits may also email you a PDF copy of all agreements you sign using the service. If you wish to receive paper copies in lieu of electronic documents you may close this web browser and request paper copies from Member Benefits by following the procedures outlined below.

Use of the Service requires a standards-compliant web-browser which supports the HTTPS protocol, HTML, and cookies. Viewing PDF documents requires additional software such as Adobe Reader or similar.

Withdrawal of Consent
You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify Member Benefits that you wish to withdraw consent and to provide your future documents, notices, and disclosures in paper format. After withdrawing consent if at any point in the future you proceed forward and utilize the electronic signature system you are once again consenting to receive notices, disclosure, or documents electronically. You may withdraw consent to receive electronic notices and disclosures and optionally electronically signatures by following the procedures described below.

Scope of Consent
You agree to receive electronic notices, disclosures, and electronic signature documents with all related and identified documents and disclosures provided over the course of your relationship with Member Benefits. You may at any point withdraw your consent by following the procedures described below. You agree to receive communications from Member Benefits regarding coverage, program availability, and other important updates via email. Your privacy is extremely important to us; we do not sell personally identifiable information to outside parties, and we follow strict security standards. You have the ability to change email delivery preferences and/or opt out at any time. For a full summary of our privacy practices, please visit the Privacy Policy page.

Requesting paper copies, withdrawing consent, and updating contact information
You will have the ability to download and print any documents you complete through the electronic signature system. To request paper copies of documents, withdraw consent to conduct business electronically and receive documents, notices, or disclosures electronically or sign documents electronically, please contact Member Benefits by telephone (800) 282-8626, or by sending an email to (quotem@memberbenefits.com) with the following subjects:

“Requesting Paper Copies” Please provide your name, email, telephone number, postal address and document title.

“Withdraw Consent” Please provide your name, email, date, telephone number, postal address.

“Update Contact Information” Please provide your name, email, telephone number and postal address.

Yes, I have read, understand, and agree to the Web Request Form and Electronic Signature Agreement.

Email*

Confirm Email *

Must be a valid email address. Your coverage documents will be delivered electronically to this address upon completion of your enrollment.

Eligibility

To be eligible for the Supplemental Health Insurance, you must meet the following Covered Class criteria for this plan:*

I warrant that I am a member of a participating organization and I am less than age 70. I understand that my enrollment will not be accepted if my eligibility cannot be verified by Member Benefits.

Member #:*

If an employee of a member, list your employers #

Do you and all other individuals to be covered under this policy have other health coverage that is minimum essential coverage within the meaning of Section 5000A(f) of the Internal Revenue Code and which is required under the Affordable Care Act?*

Yes No

Please Note: If the answer to the above question is “No,” please do not submit this enrollment form as the Company is prohibited by law from issuing this insurance policy.

Enrollment Form - Group Accident and Sickness Indemnity Insurance

This online form utilizes an SSL Certificate to ensure secure transmission of your information.

Primary Enrollee Name*

First Name

Initial (optional)

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Date of Birth

Gender*

Male Female

Telephone Number

Names of Dependents to be Covered:

Spouse or Domestic Partner Name

First Name

Last Name

Spouse or Domestic Partner Date of Birth

Child 1 Name

First Name

Last Name

Child 1 Date of Birth

Child 2 Name

First Name

Last Name

Child 2 Date of Birth

Add additional dependent children(s) Name and Date of Birth

An Eligible Dependent is:

1. is less than 25 years of age; and

a. enrolled as a part-time or full-time student at an Institution of Higher Learning

2. (FLORIDA ONLY) is less than 30 years of age; and

a. is unmarried; and

b. has no dependents; and

c. is a part-time or full-time student at an Institution of Higher Learning; and

d. is not provided coverage as a named subscriber, insured, enrollee or covered person under any other group, student, or franchise health plan or individual health benefits plan, or is not entitled to benefits under Medicare.

3. classified as an Incapacitated Dependent Child

4. (TEXAS ONLY) A grandchild under the age of twenty-five (25) if the grandchild is claimed as a dependent You for federal income tax purposes at the time application for coverage of the grandchild is made.

Beneficiary Designation for Accidental Death and Dismemberment

This online form utilizes an SSL Certificate to ensure secure transmission of your information.

Your Supplemental Health Insurance Plan comes with up to $10,000 Accidental Death & Dismemberment benefit for which you will need to designate a beneficiary.

After completing your enrollment, you will be receive a Beneficiary Change Form with your coverage documents which will allow you to make additional designations or change your designations at any time.

Primary Enrollee's Beneficiary - Name*

First Name

Last Name

Primary Enrollee's Beneficiary - Relationship*

Spouse's or Domestic Partner's Beneficiary Name*

First Name

Last Name

Spouse's or Domestic Partner's Beneficiary - Relationship*

Payment Method

This online form utilizes an SSL Certificate to ensure secure transmission of your information.

Payment Option 1 - Monthly Auto Pay
If you elect to pay by Monthly Bank Draft (ACH), you do not need to send any premium, we will automatically draft your account on a monthly basis starting on your Coverage Effective Date. Your 1st monthly draft will include the one-time $20.00 processing fee*.

Payment Option 2 - Direct Annual Billing (Initial Annual Payment via Credit Card)

If you elect this method, you will need to make your initial payment via Credit Card for the premium required to pay your coverage through the end of the group plan year (December 31st) plus the one-time $20.00 processing fee*. Your card will not be charged thereafter and you will be invoiced on an annual basis for premiums due January 1st each group plan year. November 1 and December 1 effective dates require pro-rata payment for the current plan year and payment for coverage up through the end of the following plan year (Dec 31st).

*A $20.00 non-refundable processing fee is required for each enrollment regardless of payment type. List bill options are available for businesses of 5 or more primary enrollees from the same business. Contact administrator for Firm list billing options.

Payment Method

Total Monthly Cost* $

Total Monthly Cost includes the monthly payment required to enroll in the Supplemental Health plan. A one-time $20.00 non-refundable processing fee is also due at the time of enrollment for all payment types. For employees of businesses with 5 or more participants, contact administrator for firm list billing options. Premiums are subject to change.

Total Initial Payment Due $

Required payment to pay for coverage up through the end of the plan year (Dec 31st) + $20.00 one-time processing fee. November 1 and December 1 effective dates require pro-rata payment for the current plan year and payment for coverage up through the end of the following plan year (Dec 31st).

Supplemental Health Initial Premium Due $

Annual Supplemental Health Cost $

Processing Fee $

Monthly Auto Pay/Electronic Fund Transfer Authorization

This online form utilizes an SSL Certificate to ensure secure transmission of your information.

Type of Account*

Checking Savings

Account Owner’s Name*

Bank Name*

Bank’s Transit Routing Number*

Confirm *

Your Account Number*

Confirm *

Monthly Auto Pay/Electronic Fund Transfer Authorization:
By selecting this method, if you are approved for coverage, you will receive your coverage documents and your premiums will automatically begin drafting from your account monthly beginning with your first month of coverage. If you are not satisfied with your coverage, you may write to us within 30 days and receive a refund of any premiums that have been drawn from your account.

I hereby authorize Member Benefits to initiate debit entries and to initiate, if necessary, credit entries as adjustments for any debit entries in error to my Checking account and the Financial Institution named below to debit and/or credit the same account. Member Benefits will not be held responsible for a policy lapse or cancellation due to nonpayment if withdrawal is prepared and not honored for any reason and amount due is not paid. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law and that Member Benefits and the Financial Institution may discontinue this service.

This authority is to remain in full force and effective until Member Benefits and the Financial Institution have received written notice from me of its termination in such time and manner as to afford Member Benefits and the Financial Institution a reasonable opportunity to act on it. Note: If the ACH debit is returned for non-sufficient funds, a $25 nonrefundable service fee will be applied when allowed by law.

I have read, understand, and agree to the Monthly Auto Pay/Electronic Fund Transfer Authorization

Signature of Account Owner*

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Insurance Acceptance:

THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES.

Insurance Acceptance: The undersigned represents to the best of his or her knowledge and belief that all information provided in this enrollment and any attachments hereto is true and correct. The undersigned understands that all information provided in this enrollment form and any attachments hereto is material to the Company's decision to provide this insurance, and that insurance will be provided in reliance upon the truth of such information. It is hereby agreed and understood this insurance is provided by the Company in consideration of payment of the required premium. The insurance begins on the later of: 1) on the date the policy is effective which is September 1, 2015; or 2) when We accept the eligible person’s enrollment form. If premiums are to be paid by payroll or account deduction, the undersigned authorizes such deduction by signing below.

I also understand that Federal Insurance Company will not pay benefits for any medical condition or illness due to a Pre-existing Condition. Preexisting Condition means an Accident or a Sickness for which, in the 6 months before the Covered Person becomes insured under the policy, medical advice, treatment or care was sought by a Covered Person, or was recommended by, prescribed by or received from a Physician. A condition shall no longer be considered a Pre-Existing Condition after the date a person has been covered under the Policy for 12 consecutive months.

Fraud Warning Notices:Any person who, knowingly and with intent to defraud any insurance company or other person, files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act, which is a crime. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the enrollee or Insured Person.

THE POLICY PROVIDES LIMITED BENEFITS. REVIEW THE POLICY AND YOUR DESCRIPTION OF COVERAGE CAREFULLY.

I have read, understand, and agree to the Insurance Acceptance

Primary Enrollee Signature*

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Use your mouse or finger to draw your signature above

You will receive a copy of this completed form and your coverage documents via email. Please check your junk/spam folder if you do not receive your documents within 24 hours of completing this form, and contact us immediately.

Please keep this form for your records.

Expense Protection Plan Insurance coverage is issued by FEDERAL INSURANCE COMPANY 202 Hall’s Mill Road, P.O. Box 1600, Whitehouse Station, New Jersey 08889. The Booklet-Certificate contains all details, including any policy exclusions, limitations,and restrictions, which may apply. Contract Series: 83500.

ASHIP-3000-EN (Ed. 4/14)

Your almost finished!

Important: You must click the Submit button below to complete your Web enrollment. You will immediately receive a confirmation email, which if approved, will include your coverage documents.

If you do not receive either of these emails, please first check to see if the email was filtered as SPAM, and contact us at 1-800-282-8626.

Please complete this Web enrollment by clicking Submit below.