section 1. effective date

For PHP use only

BPL #1:_____________________ BPL#2:__________________ Effective Date:____________________ Renewal Date:______________________________

Rate Basis: ACA or ______% Date Approved:_______________________ Approved By:______________________________

Application is for the following: New Group Change (only answer questions that apply to the change)

Section 1. Effective Date

1. Requested Effective Date for Coverage to Begin _ _____/_ _____/_ _ _ _ __ (MM/DD/YYYY)

Section 2. Benefit Plan(s) and Network Selections

PHP Options

3. Would you like to combine your health plan with a Consumer Driven Plan (CDP)? Yes No

Section 3. Employer Group Information

1. Employer Legal Name:_______________________________________________________________________________________________________

2. DBA Name (if applicable):____________________________________________________________________________________________________

a. Name for ID Cards: Legal Name DBA Name

3. List Owners and Percent of Ownership of Company:

Name of Owner % of Ownership

Description: Individual(s) who own the business and have a financial/vested interest in the company.

PHPNI 001 11/21

PHP Freedom

Select Consumer Driven Product

Dependent Care Assistance Program (DCAP)

Flexible Spending Account (FSA)

Health Reimbursement Arrangement (HRA)

Salary Reduction Plan with Premium Payment and HSA Contribution (POP and HSA)

If you will be electing a Consumer Driven Product through PHP, see your Broker/Account Executive for requirements/forms.

1. Benefit Plan 1 Requested:_______________________________ Benefit Plan 2 Requested:___________________________________ If this application is for a small group, please choose the Rating Method (if no selection is made, the default will beStandard - Age Banded Rating):

2. Network Selection Requested:

Standard (Age Banded Rating) Composite (Tier Based Rating)

5. Type of Business:_________________________________________________ Standard Industry Code (SIC):______________________________

6. Legal Status: C-Corp S-Corp Partnership Proprietorship LLC LLP Other _______________________________

Tax ID:_______________________________________________ Date Business Established:____________________________________________ 7. ERISA Status: Non-Exempt Exempt

Government Entity Church Plan Other ______________________

Section 3a. Billing Information

1. Billing Address:____________________________________________________________________________________________________________ (Must be an Indiana Address)

Street

____________________________________________________________IN__________________________________________ City State Zip County

Yes No If yes, would you like these divisions separated on the bill? Yes* No

2. For your Bill:

Do you have multiple divisions?

*If yes, list divisions here:

1. 4.

2. 5.

3. 6.

If exempt, select one:

8. What percentage of your employees use or speak English as their primary language? ______________________________________________________

If less than 100%, list the other language(s) and their percentage(s):

______________________________________________________ ______________________________________________________

______________________________________________________ ______________________________________________________

4. Physical Address:_________________________________________________________________________________________________________ Street

_________________________________________________________________________________________________________ City State Zip County

______________________________ ____________________________ __________________________________________ Business Phone Business Fax Company Website

Contact first name Last name

Email FaxPhone number

Is company covered under this plan? Yes No

Address State City

Zip Code County

_ _________________ __ _________________ _ ________________________________________Doing business as

_ __________________________________________________ TIN employees paid under

_________________________________________________ ________ _______________ Company Name Total employees

_______________________________________________________________ TIN

Subsidiaries 1 Information

Section 3b. Contact Information

Review the role description to determine the individual(s) who most closely meet the role described.

Primary Plan Administrator/Contact This is the Individual responsible for the day-to-day plan administration of the employer group, handling enrollments/changes and terminations.

Name Title Email Phone Fax

Decision Maker Authorized individual responsible for making the decisions for benefit plan coverage for the group. Person responsible for signing this document and renewal decision. (This may also be the owner or Plan Administrator of the group.)


Billing Contact Individual responsible for receiving the monthly premium statements and notifying PHP’s billing department of any discrepancies found (within 60 days).


Section 3c. Affiliates, Subsidiaries and Branches

Do you have any affiliates, subsidiaries, branches, or other companies? (Please list even if they are not to be included in your PHP insurance. For more information on affiliated company coverage requirements, refer to Internal Revenue Code Section 414 (b), 414 (c), 414 (m) or 414 (o).)

Yes (if yes, list here.) If No, skip to the next section.

Section 4. Current Group Size

Based on your current payroll l ist (wage and tax), how many employees do you have in each category?

Category # of Employees

Affiliate # of Employees

Total number of full-time employees (at least 30 hours or more per week):

Total number of part-time employees (less than full time):

Total number of seasonal/temporary employees:

Total number of COBRA participants:

Total number of Union employees:

Other employees ________________________________________

TOTAL EMPLOYEES: (Retirees, seasonal and temporary employees are excluded from coverage.)

_ __________________________________________________TIN employees paid under




Address State City

Zip Code County

_________________________________________________ ________ ______________ Company Name Total employees

_______________________________________________________________ TIN


_ _ ___ _ _ ___ _ __ __ __ _ __ _ __ ___ __ __ __ _ _ ___ ________________________________________Doing business as

_ _____________________________________________ TIN employees paid under

_________________________________________________ __ ____ _________ ______ _ Company Name Total employees

_______________________________________________________________ TIN




Address State City

Zip Code County


_ _ ___ _ _ ___ _ __ __ __ _ __ _ __ ___ __ __ __ _ _ ___ ________________________________________Doing business as

Waiting Period (Period i.e., 30, 60, 90 days. Waiting Period must be listed as number of days):

Waiting Period: _______________ Days

(Waiting period cannot exceed 90 days with benefits effective no later than the 91st day.)

Future employees only Current employees in waiting period & future employees Waiting period applies to:

Coverage begins:

First of the month following waiting period

Day of employment

Day waiting period is satisfied

Day after waiting period is satisfied

Terminated Employees When does coverage end for terminated employees?

Date of Termination End of the month after date of termination

Section 6. Other Carrier Information

1. Current Medical Insurance Carrier (if applicable): __________________________________________________________________

2. Prior Carrier Credit (Deductible and Out-of-Pocket): No Yes (must be submitted within 90 days of effective date)

3. Do you provide Workers’ Compensation for ALL employees: Yes No

If no, please list employees not covered:

Name Title Reason Not Covered

Current Workers’ Compensation Carrier: ______________________________________________________________________

Section 5. Eligibility/Termination

Category # of Employees

Total number of eligible employees

Total number of eligible employees enrolling*

Number of Employees with Valid Waivers (Valid Waivers includes coverage by: a spouse’s group plan, Medicare, Medicaid or TriCare, or a parent’s group plan)

Yes No (Are the benefits the same? Yes No

Hourly requirement

Total number of eligible employees waiving medical coverage for other reasons

Update Union and Retiree information to:

*Does this number include: Union employees

Retirees* Yes No (*Large Group Only - subject to Underwriting approval) (If yes, define _________________________________________)

Section 8. Continuation of Coverage

1. Are you required by law to offer COBRA coverage to your employees for the current calendar year? Yes No

If yes, COBRA Administrator_________________________________________________________

2. Are any present or former employees or dependents currently on or eligible for COBRA continuation? Yes No

If yes, please provide the following:

Name Qualifying Event Date COBRA Started Date COBRA Coverage Expires

3. Continuation of coverage while on an approved layoff or leave of absence (Note: This layoff or leave of absence provision runs concurrent withCOBRA when the employer must comply with COBRA.)

90 Days Other* ______________________________ (*Large Group Only - subject to Underwriting approval)

This contract is not in force until approved by PHP.

The undersigned applicant certifies that all answers contained in this application are true and complete.

______________________________________________________ _____________________________________________ ________________

Applicant Signature Print Applicant Name Date

______________________________________________________ _____________________________________________ ________________

Licensed Broker Signature Print Broker Name Date

PAGE 6

Section 7. Employer Contribution Toward Medical Premium

The employer must contribute a minimum of 50% of the “employee only” cost of medical coverage. If dual plans are offered, a minimum of 50% of the “employee only” cost must be contributed on each plan. Note: If employer pays entire cost, no eligible person may waive coverage due to contributory/non-contributory policies/rules.

% or $ of Employee Premium: _____________________________________

% or $ of Dependent Premium: _____________________________________

Employer group information

Group name ______________________________________________________ DBA ______________________________

Contact name ____________________________________________________ Phone number ___________________

Group size attestation

To calculate the Average Total Number of Employees: Count the total number of employees at the end of month from the

previous year and divide by 12.

Indicate how many full-time, part-time, and seasonal employees on average you employed in the previous calendar year based on available information

To calculate the Average Number of Eligible Employees: Count the total number of eligible employees at the end of each month and divide by 12. Indicate the average number of eligible employees over the previous year

Your status is determined based on the number of employees your company had during the previous year.

A “small employer” is defined as a company that employs 50 or fewer average total employees. A “large employer” is

defined as a company that employs 51 or more average total employees.

Based on the information above, please check one of the boxes below:

My company meets the definition of a “small employer.”

My company meets the definition of a “large employer.”

Employer group signature

I, the employer, am responsible for notifying PHP of any changes occurring during the course of a calendar year that could impact this employer size determination. I certify the above information is true and complete to the best of my knowledge and belief*.

Name (print) _________________________________________ Title (print) ___________________________________

Signature ____________________________________________ Date _________________________________________

*PHP reserves the right to request additional documentation in order to verify eligibility.

01/19

1700 Magnavox Way, Suite 201Fort Wayne, IN 46804

p h p n i . c o m PHP

Plan Administrator Website Authorization FormBy completing this form, the persons listed below may receive access to specific employer information on PHP’s

website. Completed forms may be faxed to your Account Manager at (260) 436-6347 or emailed to [email protected].

P H P G r o u p P r o d u c t s

20211025

GENERAL INFORMATION (Please Print)

Employer Name: ____________________________________________ Employer Phone Number: ______________________

Please list below persons requesting access to the Plan Administrator Website:(In limited circumstances we may allow the Employer’s broker or outside HR firm acting on behalf of the Employer to have access. Additional information may be required.)

1) Name: _________________________________________ Company: _________________________________________

Email: ______________________________ Signature: ________________________________ Date: ______________

2) Name: _________________________________________ Company: _________________________________________

Email: ______________________________ Signature: ________________________________ Date: ______________

By completing this form the individuals listed above will have access to the following information/actions:

By signing this form, we agree and acknowledge: 1) to maintain the confidentiality of all information provided via PHP’s website in compliance with all applicable laws and PHP’s policies; 2) to not allow any other person to learn or use our passwords; 3) to notify PHP in the event we have reason to believe somebody has a password or has attempted to access the PHP Plan Administrator website without authorization; 4) to not attempt to alter any information on the website; 5) to notify PHP within 24 hours of the authorized users separation from the Employer indentified above; 6) that PHP reserves the right to limit, suspend or terminate our access to the website; 7) on behalf of the employer, who is soley resoponsible fordetermining eligibility for enrollment, we have the authority to make changes to enrollment information according to employee elections and we willmaintain documentation supporting such changes; and 8) that the Employer will hold PHP harmless in the event of a breach of the above terms.

We hereby request and agree to electronically obtain the Group Contract and any Amendments located on PHP’s website at phpni.com. We will be notified by PHP when they are available. We understand that at any time we may opt out and request a free paper copy by submitting a written request to PHP.

_________________________________________ ________________________________________ _____________________ Plan Administrator’s Signature Printed Name Date

GROUP SPECIF IC RESOURCES ADDIT IONAL RESOURCES

• View Employee List • Administrative Forms (Enrollment Forms/Change Forms)

• View Members & Dependents • Provider Directory

• Add/Change/Term Members • Pharmacy Formulary List

• Order ID Cards/Print Temporary ID Cards • Employer Requirements and Mandates

• View Contracts and Benefits • Preventive Coverage List

• Access Schedule of Benefits • Health/Wellness Brochures

section 1. effective date

Documents