Health care for the whole you

TO COMPLY WITH CALIFORNIA LAW, WHEREVER THE TERM “SPOUSE” APPEARS IT SHALL BE CONSTRUED TO INCLUDE DOMESTIC PARTNER.

NOTICE: California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage.

Applicant Acknowledgments and Agreements

On behalf of myself and the dependents listed on Page 2, I agree to or with the following:

1. I acknowledge that by enrolling in the following plans, coverage is underwritten or administered by Aetna Life Insurance Company (referred to as “Aetna”).
2. I authorize deductions from my earnings for any contributions required for coverage and I agree to make any necessary payments as required for coverage.
3. The plan documents will determine the rights and responsibilities of the employee and dependents and will govern in the event they conflict with any benefits comparison, summary or other description of the plan.
4. I understand and agree that, with the exception of Aetna Rx Home Delivery®, all participating providers and vendors are independent contractors and are neither agents nor employees of Aetna. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed and provider network composition is subject to change. Notice of the change shall be provided in accordance with applicable state law.

Misrepresentation

Attention California Residents: For your protection, California law requires notice of the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

To the best of my knowledge, I represent that all information supplied in this form is true and complete. I have read and agree to the Conditions of Enrollment and Misrepresentation on this California Employee Enrollment/Change Request form.

TO COMPLY WITH CALIFORNIA LAW, WHEREVER THE TERM “SPOUSE” APPEARS IT SHALL BE CONSTRUED TO INCLUDE DOMESTIC PARTNER.

NOTICE: California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage.

Applicant Acknowledgments and Agreements

On behalf of myself and the dependents listed on Pages 1 and 2, I agree to or with the following:

1. I acknowledge that by enrolling in the following plans, coverage is underwritten or administered by the following entities (collectively referred to as “Aetna”):

• Aetna Dental PPO, Aetna HealthFund/Aetna DentalFund and Aetna Indemnity Dental: Aetna Life Insurance Company.
• Aetna Dental DMO®: Aetna Dental of California Inc.
• Aetna Dental Advantage, Preventive and Basic: Aetna Health of California Inc.

1. I authorize deductions from my earnings for any contributions required for coverage and I agree to make any necessary payments as required for coverage.
2. The plan documents (Schedule of Benefits, Group Agreement, Evidence of Coverage, amendments, riders or endorsements) will determine the rights and responsibilities of the employee and dependents and will govern in the event they conflict with any benefits comparison, summary or other description of the plan.
3. I understand and agree that, with the exception of Aetna Rx Home Delivery®, all participating providers and vendors are independent contractors and are neither agents nor employees of Aetna. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed and provider network composition is subject to change. Notice of the change shall be provided in accordance with applicable state law.
4. I understand and agree that, with certain exceptions described in the plan documents, DMO® plans only provide coverage for referred benefits, and that, in order to be covered, services must be performed either by a participating primary care dentist, or by the participating specialist, hospital, pharmacy, physician, or other provider as authorized by a referral from a participating primary care dentist.

Misrepresentation

Attention California Residents: For your protection, California law requires notice of the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

IT IS IMPORTANT THAT YOU READ AND UNDERSTAND THE FOLLOWING BEFORE YOU SIGN.

To the best of my knowledge, I represent that all information supplied in this form is true and complete. I have read and agree to the Conditions of Enrollment and Misrepresentation on this California Employee Enrollment/Change Request form.

Applicable to DMO and HMO Enrollees only: NOTICE OF BINDING ARBITRATION: ANY DISPUTE ARISING FROM OR RELATED TO HEALTH PLAN MEMBERSHIP MAY BE DETERMINED BY SUBMISSION TO BINDING ARBITRATION, AND NOT BY A LAWSUIT OR RESORT TO COURT

PROCESS EXCEPT AS CALIFORNIA LAW PROVIDES FOR JUDICIAL REVIEW OF ARBITRATION PROCEEDINGS. THE AGREEMENT TO ARBITRATE INCLUDES, BUT IS NOT LIMITED TO, DISPUTES INVOLVING ALLEGED PROFESSIONAL LIABILITY OR MEDICAL MALPRACTICE, THAT IS, WHETHER ANY MEDICAL SERVICES COVERED BY THIS AGREEMENT WERE UNNECESSARY OR WERE UNAUTHORIZED OR WERE IMPROPERLY, NEGLIGENTLY OR INCOMPETENTLY RENDERED. THE HEALTH PLAN AGREEMENT ALSO LIMITS CERTAIN REMEDIES AND MAY LIMIT THE AWARD OF PUNITIVE DAMAGES. SEE THE EVIDENCE OF COVERAGE FOR FURTHER INFORMATION.

I understand that I am giving up the constitutional right to have disputes decided in a court of law before a jury, and instead am accepting the use of binding arbitration. This means that members will not be able to try their case in court. I further understand that the Health Plan agreement contains limitations on certain remedies and that there may be certain limitations to the recovery of punitive damages.

Employer Notice of Occurrence of Qualifying Event For The Right to Continuation Coverage under Supplemental CalCOBRA Upon Exhaustion of Federal COBRA

California Continuation of Group Health Coverage is available to the above employee and any dependent(s) as a result of exhausting Federal COBRA.

The group health coverage under which the above individual(s) has been covered will cease because of the reason and on the COBRA Termination Date indicated above. An Election Form to Continue Coverage will be sent by Aetna to the qualified beneficiary. If the qualified beneficiary elects continuation and pays the premium, elected benefits will be reactivated without lapse in coverage.

A. Within 31 days after the above event or the termination of coverage, whichever is later, the employer must complete and return this form to:

Aetna Inc.
National Accounts Supp CalCOBRA Unit
1425 Union Meeting Rd
Blue Bell PA 19422
Telephone: 1-866-667-0656

B. Within 14 days of receipt, Aetna will send an Election Form and premium information directly to the qualified beneficiary.

C. If the qualified beneficiary wishes continued coverage, s/he must notify Aetna in writing within 60 days of the later of:

• The date Federal COBRA ceases;
• The date the employee is given notice.

D. The first premium payment must be received by Aetna within 45 days of the date the qualified beneficiary provides written notice of election.

Employer Notice of Occurrence of Qualifying Event For The

Right to Continuation Coverage Upon Exhaustion of Federal COBRA

California Continuation of Group Health Coverage is available to the above employee and any dependent(s) as a result of exhausting Federal COBRA.

The group health coverage under which the above individual(s) have been covered will cease because of the reason and on the COBRA Termination Date indicated above. An Election Form to Continue Coverage will be sent by Aetna to the qualified beneficiary. If the qualified beneficiary elects continuation and pays the premium, elected benefits will be reactivated without lapse in coverage.

A. Within 31 days after the above event or the termination of coverage, whichever is later, the employer must complete and return this form to:

Aetna
Plan Sponsor Services CalCOBRA
1385 E. Shaw Avenue
Fresno, CA 93710
Telephone: 888-595-1542

B. Within 14 days of receipt, Aetna will send an Election Form and premium information directly to the qualified beneficiary.

C. If the qualified beneficiary wishes continued coverage, s/he must notify Aetna in writing within 60 days of the later of:

• The date Federal COBRA ceases;
• The date the employee is given notice.

D. The first premium payment must be received by Aetna within 45 days of the date the qualified beneficiary provides written notice of election.

AHCX-CA (8/13) (web)