(DO NOT STAPLE) Employee Enrollment Form ' UnitedHealthcare Virgin Islands To speed the enrollment process, please be thorough and fill out all sections that apply. To Be Completed by Employer Requested Effective Date of Coverage/Date of Change / Group Name | Policy Number Date of Hire R oe 1 Empl T 4 eason for Application mployee Type of 7a LO | Le 1 New Group Plan Whew Hire (Check all that apply) PositionTitle ¢ exec u A Vea ASSIS Jan Sata OS a hi active paca is Fomtinuation Dependent Add/Delete Enrollment a.) fad os Hours Worked per wee per week Change Name/Address © Late Hourly © Salary Part time to Full time Enrollee Union © Non-Union Retired 700. OPPeduired only if Life, STD, Other Salary § or LTD Plan based on salary : Waiving Coverage Termination Other Las A. Employee information If you are waiving all coverage, please complete sections A and B. Last Name | First Name 700 fod b in 4S, Ste/CE [3 - State V/ Zip Code Home/Cell Phone bofZ2 Address uUar é E | Date of Birth oe ic Status © Single Married Divorced Widowed terres OS1 3/1/49! M Wt Language Preference if not English | ma Do you use tobacco?’ OYes i lo If yes, are you currently participating in a tobacco cessation program or do you intend to join one? Yes No Care Physician’ Existing Patient es ONO Primary Care Dentist’ E; Physician First i, 4) ey Le Lt Le (os QWs L2 | Dentist First & Last Name De Gy (4 Coxnchiae mn DS, t/a lige Br, Z yor {ioe hs : 3 Existing Patient? “Yes © No B. Waiver of Coverage Declining coverage ‘a to existence of other coverage: | | understand that by waiving coverage at this time, | | decline all coverage for Spouse's Employer's Plan Individual Plan will not be allowed to participate unless | qualify at a Myself roo by veel ere yee special enrollment period or as a late enrollee, if “Spouse e's TOM FOF EMpROye igibility applicable, or at the next open enrollment period Dependent Children rrvare | (we) have no other coverage at this time Myself and all dependents Other Coverage Provided by “UnitedHealthcare and Affiliates” Medical coverage provided by UnitedHealthcare Insurance Company Dental coverage provided by UnitedHealthcare Insurance Company Life, Short-Term Disability (STD), Long-Term Disability (LTD) Insurance coverage provided by UnitedHealthcare Insurance Company Vision coverage provided by UnitedHealthcare Insurance Company 655-2052 11/15 SOLE 16M 415 Page 1 of 4 EFTA00520760

--=PAGE_BREAK=--

Employee Name ne Ae eR List All Enrolling (Attach sheet if necessary) First Name MI [ior] Date of re Spouse - i Social Security Number Do you use tobacco?’ © Yes «No It yes, are you ee cand in « sibaace caseition program or do yoo basnd 0 jin one? Yes ", Primary Care Physician’ isti i Yes ONo Primary Care Dentist’ Existing Patient? © Yes © No Dentist First & Last Name \D# Physician First & Last Name Address Date of Birth / Do you use tobacco?’ © Yes No If yes, are you currently participating Dependent is yfabaces coualion proguios bt dace Wdoeiks is ok? 2Yes No Primary Care Physician’ Existing Patient? © Yes © No Primary Care Dentist’ Existing Patient? © Yes © No Physician First & Last Name Dentist First & Last Name Do you use tobacco?’ Yes © No If yes, are you currently participating in a tobacco cessation program or do you intend to join one? © Yes © No Primary Care Physician’ Existing Patient? © Yes © No Primary Care Dentist’ Existing Patient? © Yes © No Physician First & Last Name Dentist First & Last Name Abdaiee Aah REA Sl Re ao ee eee ee ee Permanently disabled and age 26 or older? © Yes © No ey Oe ec A Social Security Number Do you use tobacco?” © Yes No If yes, no ma apa Dependent 4. = in a tobacco cessation program or do you intend to join one? © Yes © No Primary Care Physician’ Existing Patient? © Yes ONo Primary Care Dentist’ Existing Patient? © Yes ONo Physician First & LastName___== CCC‘ ‘Dentist First & Last Name ee ee ee | ie Ee ae a a a ~ —__—_—_—__ | Permanently disabled and age 26 or older’ © Yes No Relationship* Last Name First Name al wee } | Social Security Number Do you use tobacco?’ © Yes © No If yes, are you currently participating | Dependent | ine nobaceo cessation program or do you Wiandlto crore?” Yee ONo Primary Care Physician’ Existing Patient? © Yes © No Primary Care Dentist’ Existing Patient? © Yes © No Physician First & Last Name Dentist First & Last Name a ce a Bere een. ea a IDE pe a ne pe ——_. _. —— | Permanently disabled and age 26 or older? © Yes © No (1) Tobacco means all tobacco products, including, but not limited to, cigarettes, cigars, and tobacco. You should check the box above if Eo seides teed tle or roo tbore per weak oh sovtzoe fate sorb or ceremonial use fin the past 6 na potenti? jot to Parnes eee ae ae Ca eeeenne, 1) ye ore Comenes, . Select, Pain cad ede redania reamiion yor a imary Care Physician (PCP), you must use the United! a PCP for yourself and each of your covered ) Please see representative as some plans require a Primary Care Dentist (PCD) selection. (4) For court ordered dent, umentation must be attached. If a does not reside with el y Drsiece setress on & Sipants shee Bp eon eaeeres Te for Disabled and the dependent child is oer age oer, UANSTIed, meats alee for support and is not to be self- ‘Supporting because of a physically or mentally ing injury, illness or condition, please attach a medical certification of disability. Page 2 of 4 EFTA00520761

--=PAGE_BREAK=--

Employee Name —_ os Please check the box for each coverage in which you or your dependents are enrolling. If your employer offers a choice of plans, indicate which plan selecting. Indicate the dollar amount selected for the Life and Accidental Death & Dismemberment it Supplemental Life, Short-Term Disability (STD), and Long-Term Disability (LTD) plans. Benefit offerings pendent upon employer selection. D. Product Selection Person Employee Spouse/Domestic Partner Dependent : : i Eat. 9 Chouliak Tatiana Mik beliris L0010 Fronerskaya #, at CelQVv ids Ld in the last 12 months, have you, your spouse, or your dependents had any other medical coverage? NO © YES (if yes, please complete this section.) Prior medical carrier name Effective date... End date. _ D Spouse © Child(ren) © Family : F This section must be completed. (Attach sheet if necessary.) On the day this coverage begins, will you, your spouse or any of your dependents be covered under any other medical health plan or policy, including another UnitedHealthcare plan or Medicare? © YES (continue completing this section) fio (skip the rest of this section) Name of other carrier Other Group Medical Coverage Information Type Effective Date | End Date Name and date of birth of policyholder (only list those covered by other plan) (B/S/F)* | MM/DD/YY | MM/DD/YY | for other coverage *B.Enter ‘B’ when this dependent is covered under both you and your spouse's insurance plan (married) S.Enter ‘S’ if you are the parent awarded custody of this dependent and no other individual is required to pay for this dependent's medical expenses. F. Enter ‘F’ if this dependent is covered by another individual (not a member of your household) required to pay for this dependent's medical expenses. Medicare — Employee Information: If enrolled in Medicare, please attach a copy of your Medicare ID card. © Enrolled in Part A: Effective Date © Ineligible for Part A* © Not Enrolled in Part A (chose not to enroll)** © Enrolled in Part B: Effective Date C Ineligible for Part B* © Not Enrolled in Part B (chose not to enroll)" * © Enrolled in Part D: Effective Date © Ineligible for Part D* © Not Enrolled in Part D (chose not to enroll)** Reason for Medicare eligibility: © Over 65 O Kidney Disease Disabled © Disabled but actively at work Are you receiving Social Security Disability Insurance (SSDI)? G YES ONO Start Date Medicare — Spouse/Dependent Name: © Enrolled in Part A: Effective Date © Ineligible for Part A* O Not Enrolled in Part A (chose not to enroll)** © Enrolled in Part B: Effective Date Ineligible for Part B* © Not Enrolled in Part B (chose not to enroll)** © Enrolled in Part D: Effective Date © Ineligible for Part D* © Not Enrolled in Part D (chose not to enroll)** Reason for Medicare eligibility: © Over 65 O Kidney Disease Disabled © Disabled but actively at work “Only check “Ineligible” if you have received documentation from your Social Security benefits that indicate that you are not eligible for Medicare. ** If you are eligible for Medicare on a primary basis (Medicare pays before benefits under the group policy), you should enroll in and maintain coverage under Medicare Part A, Part B, and/or Part D as applicable. Page 3 of 4 EFTA00520762

--=PAGE_BREAK=--

—kL_ Your enrollment in the plan is expressly conditioned upon your acceptance of all terms and conditions contained in this enrollment application. If you do not agree to the following terms and conditions, you may not complete your enrollment. TERMS AND CONDITIONS As a condition of my and/or my dependents’ participation in the plan, and in consideration for the privileges that come from participation in the plan, | hereby agree for myself and/or for my dependents as follows: | recognize and understand that the plan contracts with physicians and other providers that make up the plan network. | recognize that all physicians and other providers that participate in the plan network are subject to credentialing under applicable State regulations and pursuant to the plan's network credentialing process. | understand that such credentialing includes a review of provider education, training and licensure. However, by participating in the plan | hereby acknowledge and accept that the plan is not a provider of medical services, and | am aware that obtaining or not obtaining medical care involves significant risks such as serious injury and even death. | acknowledge that the credentialing of physicians and other providers does not in any way reduce this risk. | agree to assume all risks and responsibility for, and hold the plan harmless from, any and all claims for damages, including personal injury or death, medical expenses, disability, lost wages, and loss of earning capacity which may be incurred or associated with medical treatment obtained through a participating physician or other provider. | recognize that all physicians and other providers that participate in the plan network are independent contractors and not the plan's employees or agents and are solely responsible for any malpractice, adverse outcomes, or any other claims arising from medical treatment rendered to me and my dependents. | HEREBY AGREE THAT THE PLAN IS NOT RESPONSIBLE NOR LIABLE FOR ANY ADVICE, COURSE OF TREATMENT, DIAGNOSIS OR ANY OTHER INFORMATION, SERVICES OR PRODUCTS THAT | OR MY DEPENDENTS OBTAIN THROUGH A PARTICIPATING NETWORK PHYSICIAN OR OTHER PROVIDER. | recognize and understand that the plan does not recommend, endorse or make any representation about the appropriateness or suitability of any specific tests, products, procedures, treatments, services, or opinions. | recognize that the plan, plan documents, and any health and wellness information provided by the plan, are not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. | agree to confirm any medical information obtained from or through the plan with other sources, and will review all information regarding any medical condition or treatment with my physician. | HEREBY AGREE TO NEVER DISREGARD PROFESSIONAL MEDICAL ADVICE OR DELAY SEEKING MEDICAL TREATMENT BECAUSE OF SOMETHING | HAVE READ OR ACCESSED THROUGH THE PLAN. | authorize UnitedHealthcare Insurance Company and its affiliates (collectively, “UnitedHealthcare’) to obtain, use and disclose my medical, claim or benefit records, including any individually identifiable health information contained in these records. | understand these records may contain information created by other persons or entities (including health care providers) as well as information regarding the use of drug, alcohol, HIV/AIDS, mental health (other than psychotherapy notes), sexually transmitted disease and reproductive health services. | authorize any health care provider, pharmacy benefit manager, other insurer or reinsurer, hospital, clinic or other medical facility, health care clearinghouse, and any of their affiliates, representatives or business associates, to disclose my information to UnitedHealthcare and Affiliates. | understand that the purpose of the disclosure and use of my information is to allow UnitedHealthcare to facilitate the appropriate management of treatment, services, payment and benefits. | further understand that the information disclosed will not be used for purposes of eligibility, enrollment, underwriting and premium risk rating. | understand this authorization is voluntary and | may refuse to sign the authorization. | understand | may revoke this authorization at any time by notifying my UnitedHealthcare representative in writing, except to the extent that action has already been taken in reliance on this authorization. As required by HIPAA, UnitedHealthcare also requires that | acknowledge the following, which | do: | understand that information | authorize a person or entity to obtain and use may be re-disclosed and no longer protected by federal privacy regulations. This authorization, unless revoked earlier, expires 30 months after the date it is signed. { understand that | am completing a joint life and health application and that each response must be complete and accurate. | (we) request the indicated group medical coverage. | authorize any required premium contribution: is to be deducted from my earnings. | (we) have not given the agent or any other persons any required information not included on the application. | (we) understand that UnitedHealthcare is not bound by any statements | (we) have made to any agent or to any other persons, if those statements are not written or printed on this application and any attachments. Please note that if you leave out information or make a misrepresentation on this form we may be allowed by law to take one or more of the following actions: terminate or non-renew your coverage or change your premium retroactively to the date your policy became effective. Please maintain a copy of this authorization for your records. pouse Signature (if applying for coverage) mation (optional) NOTE: Responding to this question is optional and is not required. Data collected in this section will be used only to help communicate with enrollees and inform them of specific programs to enhance their well-being. This information will not be used in the eligibility process. 1. Race, check all that apply: © White © Black, African-American © American Indian/Alaska Native 0 Asian © Native Hawaiian/Pacific Islander © Other Race, please specify 2. Are you of Hispanic or Latino origin? © Yes © No Page 4 ot 4 EFTA00520763