Employee Enrollment Application

Group Size 51+ Eligible Employees - Medically Underwritten Your Anthem enrollment application is inside. It is essential that you read it carefully and complete all the necessary sections. If you are a new enrollee: a) applying for health, vision and/or dental coverage plus life and disability insurance, please complete sections 2, 4, 5, 6, 7, 8, 9, and 10. Your signature is required in Section 10. b) applying for health, vision and/or dental coverage but waiving life and disability insurance, please complete sections 2, 4, 5, 6, 8, 9, 10, and 11. Your signature is required in Section 10. c) applying for life and disability insurance but waiving health coverage, please complete sections 2, 5, 6, 7, 10 and 11. Your signature is required in Section 10. d) waiving all coverage, please complete sections 2, 5, and 11. Your signature is required in Section 11. If you are adding a dependent(s), complete section 3 in addition to the above.
If you are a new enrollee in Anthem ByDesign Buy-up Coverage: Applying for Anthem ByDesign Buy-up Health, Dental or Vision coverage, please complete the appropriate PPO check box under section 4 Type of Coverage/Plan and write in the Health, Dental or Vision plan number of the benefit you have selected on the line provided next to the PPO check box. Applying for Anthem ByDesign Buy-up Short Term Disability (STD) or Long Term Disability (LTD) coverage, please complete the STD or LTD check box under section 7 Life and Disability Insurance and write in the benefit percentage you have selected on the line provided next to STD or LTD.

It is important that you read and understand the Significant Terms, Conditions and Authorizations in Section 10. Note: You may be required to supply additional information.

Thanks for choosing Anthem Blue Cross and Blue Shield. www.anthem.com
Life and disability products are underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. In Indiana: Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. In Kentucky: Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, Inc. In Ohio: Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensees of the Blue Cross and Blue Shield Association. Registered marks Blue Cross and Blue Shield Association.

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Enrollment Application

Group Size 51+ Eligible Employees - Medically Underwritten Please complete in ink and return to your employer. Use extra sheets of paper if necessary. All information given should apply to this employer. Anthems Primary Care Physician (PCP) listings, for HMO/POS products can be obtained through www.anthem.com 1. Employer/Group Use: Employer Name and Address: Group # Sub-group #/ Life Division # Request Effective Date
/ /

Life Classification

Applicant #/Dept. name Pre-ex (date) / /

Anthem use: Plan Health Effective Date Life Effective Date Dental Effective Date Vision Effective Date PCP COB / / Yes No / / / / / / Yes No 2. Reason for Application 3. Status Change/Event / / Adoption* Event date Waiver New enrollment Marriage New hire Annual open Legal Guardianship* Rehire (date) / / enrollment Birth Other (N/A to Life) Add dependent (see section 3) *Include legal documentation. COBRA Qualifying event Event date / /

4. Type of Coverage/Plan Health Coverage Dental Coverage Vision Coverage Life Coverage HMO* POS* PPO PPO Vision Life SM Blue PrioritySM*1 Blue Blue Access Traditional (see section 7) Traditional Hospital Surgical (1Ohio only - a (Indiana and Ohio PPO health insuring only) corporation product or HIC) Dental Blue Employee only Lumenos Health Savings Account Dental Blue Choice 100 Employee + spouse Lumenos Health Reimbursement Account Dental Blue Choice 300 Employee + child(ren) Lumenos Health Incentive Account Employee only Family coverage Employee only Employee + spouse No coverage Employee + spouse Employee + child(ren) Employee + child(ren) Family coverage Family coverage No coverage No coverage Anthem will facilitate the opening of a Health Savings Account in your name, if directed by your Employer. 5. Employee Information *Only complete Primary Care Physician (PCP) information if enrolling in HMO or POS products. Date of birth Age Sex Social Security # (SS# required for Last name First name, M.I. Weight Single Height M Lumenos Health Savings Account) Divorced / / F Married Home address City State Zip code eMail Address Full time hire date / / County (KY residents include Municipality) Home telephone Business telephone ( ) ( ) Are Retired? Disabled? Hospitalized? Occupation you: Yes Yes Yes No No No Anthem PCP name and address*

Hours working per week Income reported by: W2 1099 Other: New patient?* Anthem PCP ID number* Yes No 6. Family Information *Spouse and dependents to be covered (Attach a separate sheet if necessary)* Only complete Primary Care Physician (PCP) information if enrolling in HMO or POS products. Son Relationship Spouse Fulltime student? 1 Last name First name, M.I. Daughter Other to applicant Yes No Yes No (If Yes, provide full address) Is dependents address different than applicants address? No Date of birth Sex Social Security # Height Weight Eligible for federal income tax exemption? Yes Yes No (If yes, include legal documentation) M Court ordered health care coverage? / / F Yes No (If yes, give reason) Currently hospitalized or disabled? Anthem PCP name and address* Anthem PCP ID number* New patient?* Yes No Son Relationship Spouse Fulltime student? Daughter Other to applicant Yes No Yes No (If Yes, provide full address) Is dependents address different than applicants address? No Date of birth Sex Social Security # Height Weight Eligible for federal income tax exemption? Yes Yes No (If yes, include legal documentation) M Court ordered health care coverage? / / F Yes No (If yes, give reason) Currently hospitalized or disabled? Anthem PCP ID number* New patient?* Anthem PCP name and address* Yes No 2 Last name First name, M.I.
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Son Relationship Spouse Fulltime student? Daughter Other to applicant Yes No Yes No (If Yes, provide full address) Is dependents address different than applicants address? No Date of birth Sex Social Security # Height Weight Eligible for federal income tax exemption? Yes Yes No (If yes, include legal documentation) M Court ordered health care coverage? / / F Yes No (If yes, give reason) Currently hospitalized or disabled? Anthem PCP ID number* New patient?* Anthem PCP name and address* Yes No 3 Last name First name, M.I. 7. Life and Disability Insurance Short Term Disability % Basic Life Basic AD&D Anthem By Design Short Term Disability-BUY UP Life Class Long Term Disability % Dependent Life Supplemental AD&D Anthem By Design Long Term Disability-BUY UP Are you currently active at Anthem By Design Basic Life-BUY UP Yes No work? Supplemental Life: x annual earnings OR $ Hour Week Month Year (Complete separate election form) Current Income: $ If no, reason: Primary Relationship to applicant Age Last name First name, M.I. Social Security # Beneficiary Contingent Last name Relationship to applicant Age First name, M.I. Social Security # Beneficiary 8. Other Health Coverage Please check one: YES (completed below.) NO On the day your coverage begins, list family members, including yourself, who will be covered by any other health coverage. Provide name, phone number and address of the HMO or insurance company Policy/certificate holders name Social Security number Policy/certificate number Date of birth Effective date

Relationship to applicant Medicare Part B effective date ESRD onset date

If you and/or your dependents are enrolled in Medicare or Medicaid, complete the following. Enrollees name(s) Medicare Part A Medicare/ Medicaid ID# effective date

Medicare Part D ID# Reason for Medicare entitlement: Disability ESRD & Disability Age

Medicare Part D Carrier

Medicare Part D effective date

Medicare Part D term date

End Stage Renal Disease (ESRD)

9. Prior Health Coverage Please check one: YES (completed below.) NO Group name/ID# Have you been covered by Anthem within the past two (2) years? Yes No Policy/Certificate #: List prior carrier(s) Have you and/ or your dependents had prior coverage with another carrier(s) within the past two (2) years? Yes No Please check the type of prior coverage Employee Employee/ Spouse Employee/ Child(ren) Employee/ Spouse/ Child(ren) Termination reason: Divorce/legal separation Group plan terminated Death of spouse COBRA coverage exhausted Other: Employer/group contribution ceased

Dates Policy in effect: Dates Policy in effect:

Employment terminated

Significant Terms, Conditions and Authorizations (TERMS) Please read this section carefully before signing the application. 1. I may not assign any payment under my Anthem Blue Cross and Blue Shield program unless allowable by law. 2. I authorize deduction from my wages/pension, if necessary for the required premium for the coverage for which I, or any dependents have applied. 3. I am applying for the coverage selected on this application. If I select a coverage, or combination of coverages, not available to me and / or a class for which I am not eligible, I agree that my selection(s) is hereby automatically amended to be consistent with the employers application. 4. I understand that, to the extent permitted by law, Anthem reserves the right to accept or decline this application (and that Anthem Life Insurance Company may accept only certain persons or conditions for coverage) and that no right whatsoever is created by this application. I also understand that this coverage, if approved, may exclude coverage for pre-existing conditions. (Ohio only unless I applied for HMO/HIC coverage, in which case there is no such exclusion.)
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I acknowledge that I have read the Significant Terms, Conditions and Authorizations, and I accept such provisions as a condition of coverage. I represent that the answers given to all questions on this application are true and accurate to the best of my knowledge and I understand they are being relied on by Anthem in accepting this application. I understand that any misstatements or failure to report new medical information prior to my effective date may result in a material change to coverage or premium rates. Any material misrepresentation or significant omission found in this application may result in denial of benefits or rescission or cancellation of my coverage(s). Ohio: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Kentucky: Any person who knowingly and with intent to defraud any insurance company, health maintenance organization, self-insured plan, or other person, files an application for insurance or other form of health care coverage 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.
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5. I am responsible to timely notify my employer of any change that would make me or any dependent ineligible for coverage. 6. Ohio: If applying for HIC/HMO coverage, I understand that I may cancel my membership by providing written notice to Anthem within 72 hours of signing this application. 7. By signing this application, I agree and consent to the recording and / or monitoring of any telephone conversation between Anthem and myself. 8. THIS PARAGRAPH APPLIES ONLY TO MEMBERS OF OHIO GROUPS, AND DOES NOT APPLY TO MEMBERS OF INDIANA OR KENTUCKY GROUPS: I understand that Anthem may collect personal information about me from outside sources, and that both personal and privileged information may only be disclosed to outside parties without my authorization if such disclosure is permitted by both the HIPAA Privacy Regulations (45 C.F.R. Parts 160 & 164) and the Ohio Revised Code 3904.13. I also understand that under the HIPAA Privacy Regulations and Ohio law, I have a right to see and correct personal information that Anthem collects about me, and that I may receive a more detailed description of my rights under these laws by writing to Anthem.

I give this authorization for and on behalf of any eligible dependents and myself if covered by the Plan. I am acting as their agent and representative. Your health coverage will be provided by one of the following companies based upon the state in which your employer, trust or association is located: In Indiana: Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. In Kentucky: Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, Inc. In Ohio: Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Thank you for choosing Anthem Blue Cross and Blue Shield

10. Read the TERMS section above carefully before signing. Please review your application for errors or omissions. By signing this, I am indicating that I have read and understand the language in the TERMS section of this application and agree to all of its terms. Applicant Signature Date

11. Waiver of coverage for employee and / or any eligible dependent not enrolling Check all that apply. Waiving: Health Dental Vision Life All Name of person waiving Employer name Carrier:

Already protected by coverage of: Spouse Parent None Anthem (give certificate/policy #) Other carrier (give name, ID #) All Already protected by coverage of: Spouse Parent None Anthem (give certificate/policy #) Other carrier (give name, ID #) All Already protected by coverage of: Spouse Parent None Anthem (give certificate/policy #) Other carrier (give name, ID #) All Already protected by coverage of: Spouse Parent None Anthem (give certificate/policy #) Other carrier (give name, ID #)

Check all that apply. Waiving: Health Dental Vision Life Name of person waiving Employer name Carrier:

Check all that apply. Waiving: Health Dental Vision Life Name of person waiving Employer name Carrier:

Check all that apply. Waiving: Health Dental Vision Life Name of person waiving Employer name Carrier:

Check all that apply I certify that I have been given an opportunity to apply for Anthem Blue Cross and Blue Shield coverage and after careful consideration, have decided not to take advantage of this offer. In the event I wish to apply for such coverage hereafter, I may do so, subject to established procedures. If I am declining enrollment for myself or my dependents (including my spouse) because of other health insurance coverage, I may in the future be able to enroll myself or my dependents in this plan, provided that enrollment is requested within 31 days after other coverage ends. My dependent(s) or I may be subject to pre-existing condition restrictions or waiting periods specified in the group certificate, if a dependent or I are late enrollees. In addition, if I have a dependent as a result of marriage, birth, adoption or placement for adoption, I may be able to enroll myself and my dependents provided that I request enrollment within 31 days after the marriage, birth, adoption or placement of adoption. I certify that I have been given an opportunity to apply for the available group life benefits offered by my employer/group, the benefits have been explained to me, and I and / or my dependent(s) decline to participate. Neither my dependent(s) nor I were induced or pressured by my employer/group, agent or life carrier, into declining this coverage, but elected of my (our) own accord to decline coverage. I understand that if I wish to apply for such coverage in the future, I may be required to provide evidence of insurability at my expense. Applicant Signature Date

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Employee Health Questionnaire

Spouse name

Coverage

m Employee only
Dependent 1 Dependent 2

m Employee/spouse

m Employee/child(ren)

m Family

Dependent 3

Please answer the following questions for yourself AND any eligible dependents. Please note that no one will be denied coverage on an individual basis due to answers provided below. 1. Has anyone been treated for a serious illness, been hospitalized or had surgery in the past 5 years, is currently hospitalized or been advised that medical treatment, diagnostic testing, surgery, or hospitalization is necessary with the exception of AIDS/HIV? ..................... m Yes m No If YES, please explain below. __________________________________________________________________________________ 2. Is anyone currently being treated or been advised to seek treatment or counseling for any of the following? ........................................................... m Yes m No If YES, please check condition(s) that apply. m cancer m heart disease m back/spinal disorder m chemical dependency m Crohns Disease/ulcerative colitis m stroke m blood disorders m liver disease m chronic respiratory disease m obesity m diabetes m muscular disorder m high blood pressure m chemical dependency/alcoholism m mental illness m kidney disorder m brain tumor m nervous system disorders m transplants m currently pregnant? If, yes, due date ____________________ m other? __________________ If YES, please explain below. __________________________________________________________________________________ 3. Do you or your dependents regularly take medication? ......................................................................................................................................................... m Yes m No If YES, please explain below. __________________________________________________________________________________ 4. In the past 5 years have you or any of your dependents been diagnosed with AIDS or HIV? .......................................................................................... m Yes m No If YES, please explain below. __________________________________________________________________________________ Explain YES answer to any question. Give complete details to avoid delay. (Attach a separate sheet of paper if necessary) Question no. Name of Individual Diagnosis Treatment Medication Onset Date Date(s) of Treatment Hospitalized? Surgery? Recovered? (Y/N) (Y/N) (Y/N)

IOHFR3599A (8/08)

Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

www.anthem.com

I represent that all answers on this Questionnaire are true and accurate to the best of my knowledge and I understand they will be relied upon by Anthem Blue Cross and Blue Shield in accepting this application. I understand misstatements or failures to report new medical information prior to my effective date may result in a material change to coverage or premium. Material misrepresentations or significant omissions in this application may result in increased premiums, benefits being denied or coverage(s) being rescinded or cancelled. Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. If applying for HMO/HIC coverage, I understand that I may cancel my membership by providing written notice to Anthem within 72 hours of signing this application. 3904.04 NOTICE OF INFORMATION PRACTICES: I understand that Anthem may collect personal information about me from outside sources, and that both personal and privileged information may only be disclosed to outside parties without my authorization if such disclosure is permitted by both the HIPAA Privacy Regulations (45 C.F.R. Parts 160 and 164) and the Ohio Revised Code 3904.13. I also understand that under the HIPAA Privacy Regulations and Ohio law, I have a right to see and correct personal information that Anthem collects about me, and that I may receive a more detailed description of my rights under these laws by writing to Anthem. 3904.06 I understand that the length of time such authorization shall remain valid shall be no longer than 30 months from the date the authorization is signed. I agree that this executed Questionnaire will become part of the Application and any contract issued on it.

Employee signature

Date