(D0 NOT STAPLE) Employee Enrollment Form Virgin Islands 1) UniteaHtealthcare To speed the enrollment process, please be thorough and fill out all sections that apply. To Be Completed by Employer Req Group Name Date of Hire / / Reason for Application ee nisl New Group Plan Postion Ttle €xecurtive ass:s Zonk « te cennae ——§ Dependent Add/Delete Hours Worked per week _ Part time to Full time Required only if Life, STD, ] © Waiving Coverage or LTD Plan based on salary | © Other g CTL New Hire Annual Open 3 Change Name/Address 0 Loam e Union GNon-Union Retired © Termination | > Other ted Effective Date of Coverage/Date of Change / Policy Number Employee Type (Check all that apply) Active COBRA © State Continuation Start dt ey a Enroliment Enddt__/ / Hourly © Salary ee eng SN ceerage pase complete sectons A ant “Laryna Wk = homer V1 |r Date of Birth Marital Status © Single Mi: M Te | Language Preference coos Email Address Do you use tobacco?’ 3 Yes 0 If yes, are you currently participating in a tobacco cessation program or do you intend to join one? © Yes ©No Existing Patient? es eZ Care Physician’ (27 Wr t- Physician First & Last Dispouers Empoyers Pan inchdual Poe I deciine all coverage for. | ‘/ Spouse's Employer's Plan Myself Spouse ADependent Children 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 Vision coverage provided by U: fedHealthcare Insurance SHEE NEVI 415 Page 1 ot 4 Primary Care Dentist : Dentist First & Last Name Dr, Guide Sarnachiare | | understand that by waiving coverage at this time, | will not be allowed to participate unless | qualify at a Special enrolment period or as a late enrollee, if applicable, or at the next open enrollment period. , Long-Term Disability (LTD) Insurance coverage provided by UnitedHealthcare Insurance Company 4 GS5-2062 1015 EFTA00521831

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Employee Name List All Enrolling (Attach sheet if necessary) C. Family information First Name Mi Last Name | Sex ] Date of Birth }OMOF / / Spouse = st ey eer ayt os } it i - /Domestic | Social Security Number Do you use tobacco?’ ©) Yes ©)No If yes, are you currently participating Partner | | |- el [- | ip in a tobacco cessation program or do you intend to join one? [Yes ONO ca is | 1 PAPE et ae ld cea =. oH i Primary Care Physician® Existing Patient? © Yes © No Primary Care Dentist? Existing Patient? © Yes ©No Physician First & Last Name - ie i‘ Dentist First & Last Name __ Relationship’ i . | Last Name First Name Date of Birth / jaMoF I Relationship Oo you use tobacco?’ Yes (No Hf 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 Do you use tobacco” © Yes CNo If yes, are you currently participati in a tobacco cessation program or do you intend to joinone? © Yes © Primary Care Dentist’ Existing Patient? © Yes ONo Dentist First & Last Name Ibe Permanently disabled and age 26 or older’ © Yes © No ; Last Name Mi | Sex Date of Birth Relationship* MOF ! ! Social Security Number Do you use tobacco?’ Yes No If yes, are you currently participating Dependent a a ina tobacco cessation program or do you intend to joinone? © Yes © No Primary Care Physician’ Existing Patient? © Yes © No Primary Care Dentist’ Existing Patient? © Yes © No Physician First & Last Name Dentist First & Last Name IDe Address Permanently disabled and age 26 or older* © Yes ONo Sex Date of Birth OMoF / / Existing Patient? ©Yes © No Primary Care Dentist’ Existing Patient? © Yes ONo Dentist First & Last Name \D# Permanently disabled and age 26 or older © Yes © No fawaien seve mae Toots” Select, Plus, you to choose & covered Primary Care Physician’ Existing Patient? © Yes Physician First & Last Name Address ID aii EFTA00521832

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Employee Name enrolling. Please check the box for each coverage in which you or you ints are pei menoutl je It your employer offers a choice of plans, indicate which plan you are selecting. Indicate t pilicied for the Life and Accidental Death & Dismemberment (AD&D), Supplemental Lite Short-Term Disability (STD), and Long-Term Disability (LTD) plans. Benefit offerings are dependent upon employer selection. Person Vision Basic Lit/AD&D | Supp Life/AD&D Employee . $ <4 Spouse/Domestic Partner Dependent Relationship Insurance Information jin the last 12 months, have you, your spouse, or your dependents had any other medical coverage? OYES (if yes, please complete this section.) Prior medical carrier name Effective date... Enddate__ Prior type: CEmployee Spouse = Child(ren) a Family 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) thio (skip the rest of this section) Name of other carrier Other Group Medical Coverage Information Name and date of birth of policyholder (only list those covered by other plan) 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___________—« Ineligible for Part 8° © Not Enrolled in Part B (chose not to enroll)** © Enrolled in Part O: Effective Date O Ineligible for Part D* © Not Enrolled in Part D (chose not to enroll)** Reason for Medicare eligibility: © Over 65 © Kidney Disease © Disabled © Disabled but actively at work Are you receiving Social Security Disability Insurance (SSDI)? GC YES ONO StartDate Medicare - Spouse/Dependent Name; © Enrolied in Part A: Effective Date == Ineligible for Part A* © 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 Kidney Disease Disabled © Disabled but actively at work *Onty 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. 7 on. elites lead inate RenteelaadSiek tc Page 3 of 4 EFTA00521833

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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 enroliment. 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 employees or agents and are solely responsible for any malpractice, outcomes, or any other claims arising 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. J 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 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 I 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 contributions to be deducted from my earnings. | (we) have not given the not included on the application. | (we) understand that UnitedHealthcare is not bound by agent or any other persons any required 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 mistepresentation 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. 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: 0 White © Black, African-American © American Indian/Alaska Native © Asian © Native Hawaiian Pacific Islander © Other Race, please specify 2. Are you of Hispanic or Latino origin? © Yes © No Page 4 of 4 EFTA00521834