mcafr1167cev

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*MCAFR1167CEN 3/09 01MCAFr1167CEV 3/CASMEEAPP (3/09)

S Nhm / Gop

1c. Bo Him Th Gic - vui lng tham vn cp trn ca qu v m bo nhng la chn ny kh dng trc khi chVision Coverage please check with your employer to make sure these options are available before selecting:oBle View HOC / Or oBle View Pls c cug cp bi Atem Blue Cross Life ad healt Isurace Comp

offered by Atem Blue Cross Life ad healt Isurace Compay

EmployeeElect cho Cc Nhm Nh c 2-50Thnh VinCc chng tnh chm sc sc khe do Anthem BleCoss cng cp. Cc chng tnh bo him do AnthemEmployeeElect for 2-50 Member Small GroupsBle Coss Life and Health Insance Company gii thiHealth cae plans offeed by Anthem Ble Coss.Insance plans offeed by Anthem Ble Coss Life andHealth Insance Company

Vui lg dg mc e/ my i, d k cc trag b trog bo v tg ti c v gi li co Qu Tr nm ca qu v. Qu v, vi, pi i vo g k y.Qu v l gi cu trc im duy t v s c xc v o c ca g k. tr k g cm tr, vui lg tr li tt c cc cu i v k t cg gi gy tgvo g k.

1b. Bo Him Nha Khoa - vui lng hi cp trn ca qu v bit cc la chn Nha Khoa no kh dng trc khi ch Dental Coverage please ask your employer which Dental options are available before checking your selectoDental Ble Silve 100-80** oHigh Option PPO** oDental Net* oKhc / Othe_____________________oDental Ble Silve Pls 100-80** oStandad Option PPO**oDental Ble Gold 100-80** oBasic Option PPO**oDental Ble Gold Pls 100-80**oDental Ble Platinm 100-80**oDental Ble Platinm Pls 100-80**

i vi chng tnh DentalNet bn tn, bn phi chnmt S Phng Khm NhaKhoa:Fo above Dental Net plan,you must select a DentalOffice Numbe:

*c cug cp bi Atem Blue Cross **c cug cp bi Atem Blue Cross Life ad healt Isurace Compay*offered by Atem Blue Cross **offered by Atem Blue Cross Life ad healt Isurace Compay

Bo Him Nha Khoa T NguynVoluntary Dental CoverageoDental PPO**oDental Save SelectHMO* B

pi c mt S Pg Km n

Koa ( b tri) You must select a Detal Officenumber (to te left)

anthem.com

1a. Bo Him Y T - vui lng trao i vi cp trn ca qu v bit cc la chn Y T no kh dng trc khi ch Medical Coverage - please ask your employer which Medical options are available before checking your selectio Pemie PPO $10 Copay*o Pemie PPO $20 Copay*o Pemie PPO $30 Copay*o PPO $20 Copay**o PPO $30 Copay*o PPO $40 Copay*o PPO $25 Copay Genrx**o PPO $35 Copay Genrx**o PPO $45 Copay Genrx**

oSolution 2500 PPO**oSolution 3500 PPO**oSolution 5000 PPO**oElements Hospital

Pefeed**oElements Hospital Plus**oElements Hospital**oLumenos HIA Plus 750**oLumenos HIA Plus 500**

oLumenos HSA 2000(100/70)**






oHigh Deductible EPO*

oHMO $10 100%*oHMO $25 100%*oClassic $20 HMO*oClassic $30 HMO*oClassic $40 HMO*oSave $20 HMO*oSave $30 HMO*oSave $40 HMO*oSelect $25 HMO*oSelect $35 HMO*

oLumenos HSA 1500 (100/70)**o Advantage PPO $25 Copay**oSave PPO **oBasic PPO **oPPO 2400 (Thch Hp HSA)** PPO 2400 (HSA-Compatible)**oPPO 3500 (Thch Hp HSA)** PPO 3500 (HSA-Compatible)**oLumenos HIA Plus 3000**oPowe HealthFund 750**oPowe HealthFund 500**

nu hMO, y cug

s ca bc s trog mIf hMO, be sure to propysicia umber i secti

*c cug cp*offered by Atem Blue C

**c cug cp bi AtBlue C

Life ad healt IsuraComp

**offered by Atem Blue CLife ad healt Isura

Comp

N cp tn ca v y c, Anthem BleCoss Life and Health s to i kin m TiKhon Tit Kim Chm Sc Sc Khe mangtn ca v.If diected by yo employe, Anthem Ble Coss

Life and Health will facilitate the opening of aHealth Savings Accont in yo name.

oKhc / Othe: ________

n ng K CaNhn VinEmployee Applicatio

Please complete usig black ik/type, seal te iside pages for privacy ad retur to your Group Admiistrator. You, te employee, must completeapplicatio. You are solely resposible for its accuracy ad completeess. To avoid te possibility of delay, please aswer all questios ad be susig ad date your applicatio.

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S An Sinh X Hi hoc S ID caNgi Phi Ng/DPSpose/DP Social Secity o ID No.

S An Sinh X Hi hoc S IDSocial Secity o ID No.

1d. Bo Him Nhn Th - vui lng tham vn cp trn ca qu v m bo nhng la chn ny kh dng trckhi chn:Life Coverage please check with your employer to make sure these options are available before selecting:

Optional Dependent Life Insance (ch p dng n c cptn ca v cng cp)Optional Dependent Life Insance (only if offeed by yo employe)o$10.000/$1.000 ($10.000 ngi phi ngu/con 6 thng-24 tui;

$1.000 di 6 thng)$10,000/$1,000 ($10,000 spouse/child 6 months-24 ys; $1,000less than 6 months)

o$5.000/$500 ($5.000 ngi phi ngu/con 6 thng-24 tui; $500di 6 thng)$5,000/$500 ($5,000 spouse/child 6 months-24 ys; $500 lessthan 6 months)

Spplemental Life Insance (ngoi Tem Life, n c cng cp)Spplemental Life Insance (in addition to Tem Life, if it is offeed)

oC / YesoKhng / NoS tin / Amont: o$15.000 o$25.000 o$50.000 o$100.000c cung cp bi Anthem Blue Cross Life and Health Insurance Companyoffered by Anthem Blue Cross Life and Health Insurance Company

*MCAFR1167CEV 3/09 02*MCAFr1167CEV 3/09 02

2. Vui lng cung cp thng tin ng k sau y (phi c cp tr in):

Please provide the following enrollment information (must be completed by the employee):ng k theo nhm mi Nhn vin mi COBrA Ngy Hi Lc ca Chng Tnh COBrA/Cal-COBrA: New gop enollment New hie COBrA/Cal-COBrA Effective Date: B sng gia nh Thay i bo him Cal-COBrA Family addition Change of coveageng k t Khc / Othe: ________________________

Late enollment (Ngi ng k Cal-COBrA phi np ph bo him thng u tin) (Cal-COBrA applicants must submit fist months pemium)

H / Last Name Tn / Fist Name Tnm /M.I.


Thnh ph / City Tibang /State

M ZIP / ZIP Code S in Thoi Nh / Home Phone No.

( )

Tn Ca cp tn / Employe Name Ngh Nghip/Chc DanhOccpation/Job Title

S in Thoi Cng TyBsiness Phone No.( )

Ngy Tyn Dng

Hie Date

oBn thi gian

Pat timeoTon thi gianFll time

Ngi Hng Bo Him Nhn Th H Tn Tn mLife Insance Beneficiay Last Name Fist M.I.

Mi an h / relationship

Tin lng (Bt buc)

Salay (reied)$

S Gi Lm Vic Mi Tn

# of Hos Woked pe Week

Tnh Tng Hn NhnMaital Statsc Thn Kt Hn

Single Maiedo Bn Sng Chng (DP) Domestic Patne (DP)

S Ngi Ph Thck c Ngi Phi Ng/DP# of Dependentsinclding Spose/DP

Hng gi / Holy

Hng tn / Weekly Hng thng / Monthly

a Ch Nh (Khng chp nhn Hp Th tr phi l Hp Th nng thn) S Cn HHome Addess (P.O. Box not acceptable unless rural P.O. Box) Apt No. S An Sinh X Hi hoc S ID caNgi Phi Ng/DPSpose/DP Social Secity o ID No.

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*MCAFR1167CEV 3/09 03MCAFr1167CEV 3/

3. Vui lng cho chng ti bit v bn thn qu v v nhng ngi ph thuc tiu chun ng k: Please tell us about yourself and your eligible enrolling dependents:

Lu :N c bt k ngi ph thc ng k no khng sng ti a ch ghi Mc 2 tang tc, vi lng cng cp a ch ca h mt t giy ing.Note:Any enolling dependent(s) who do not live at the addess listed in Section 2 on pevios page, please povide thei addess(es) on a sepaate piece of pape.

ngi p tuc tiu cul mt ngi phi ng hoc bn sng chng hp php ca mt nhn vin; con ca mt nhn vin l ngi gim h hp php l di ca ngcon v l ngi np lnh ta n thit lp yn gim h hp l; (cc) con ngoi gi th ca nhn vin hoc, ca ngi phi ng/bn sng chng ca nhn vin

ngi (i) di 19 ti, hoc, (ii) ti [19 n 24 ti]l ngi ti chn lm ngi ph thc v mc ch nh th th nhp lin bang v l hc sinh ton thi gian; hotn 19 ti l ngi ti chn lm ngi ph thc v mc ch nh th th nhp lin bang v khng c kh nng lao ng ni sng bn thn do thng tn, bnhoc bnh tng gy khyt tt v th cht hoc tinh thn. Hng nm, Anthem Ble Coss v/hoc Anthem Ble Coss Life and Health Insance Company c th y cbn chng minh vic i hc hoc chng minh tnh tng khyt tt ko di ca a t do bnh tt hoc thng tn v th cht hoc tinh thn. C th cn n vn bn cminh mi an h i vi nhng tng hp ng k nht nh. V d nh, mt thnh vin hin ti l ngi c thm mt ngi phi ng hoc bn sng chng ph thc cng cp bn sao Giy ng K Kt Hn, Tyn B qan H Sng Chng hoc giy t tng ng. ng k cho mt ngi con ni, cn c giy t chng minh hp pv vic ni con (hoc nh nhn con ni).Eligible depedetis an employees lawfl spose o domestic patne; a child of an employee who is the pemanent legal gadian of that child and fo whom a valid cot establishing gadianship has been sbmitted; the nmaied child(en) of the employee o, of the employees spose/domestic patne who ae (i) nde age 19 o, (ii) ageto age 24]who alify as dependents fo fedeal income tax pposes and ae fll-time stdents; o (iii) ove age 19 who alify as dependents fo fedeal income tax ppand incapable of self-sstaining employment de to a physically o mentally disabling injy, illness o condition. Annally, Anthem Ble Coss and/o Anthem Ble Coss LifeHealth Insance Company may eie witten poof of stdent stats o poof of childs contining disability de to physical o mental illness o injy. Witten poof of elationmay be eied fo cetain enollments. Fo example, an existing sbscibe who is adding a dependent spose o domestic patne mst povide a copy of a Maiage CetificDeclaation of Domestic Patneship o eivalent docment. Fo enollment of an adopted child, legal evidence of adoption (o intent to adopt) is eied.N h ca ngi phi ng khc vi h ca v, th ngi c phi l bn sng chng hay khng?

If sposes last name is diffeent than yos, is he/she a domestic patne? o C / Yes o Khng / NoB SuNG GIA NH: Ngy kt hn hoc tyn b an h sng chng: Ngy nhn con ni:FAMILY ADDITION: Date of maiage o domestic patneship declaation: Date of adoption:

S An Sinh X Hi hoc S ID Ngi Phi Ng/DPSpose/DP Social Secity o ID


Gii tnhSex

HLast Name

TnFirst Name

TnmMI C

hiucao

Height

Cnnng

Weight

oNam

MaleoN FemaleoNam MaleoN FemaleoCon tai SonoCon gi DaghteoCon tai SonoCon gi Daghte

oCon tai SonoCon gi DaghteoCon tai SonoCon gi Daghte

B h N h H i T i

o

o

Khuyttt

Disabled

Ngy sinhThng Ngy Nm

Birthdate Mo. Day Year

Chng Trnh Chm ScChnh

S Ca Bc Shoc -S Nhm Y T/IPA

3 ch s.Primary CarePhysician No.

or 3-digit Medical Group/IPA No.

Nhn vinEmployee

Ngi Phi Ng/DPSpose/DP

CH I VI CC CHTRNH HMO:

HMO PLANS ONLY:

o

o

o

o

o

o

o

o

oC YesoKhng NooC YesoKhng NooC YesoKhng NooC YesoKhng NooC YesoKhng No

o

o

oC YesoKhng No

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4. Vui lng in vo nu qu v t chi bo him cho bn thn v/hoc bt k ngi ph thuc tiu chun no:Please complete if you want to decline coverage for yourself and/or any eligible dependents:

Loi Bo Him:Type of Coverage:

Bo him y tMedical coveage

Bo him nha khoa(n c gii thi)Dental coveage(if offeed)

Bo him th gic(n c cng cp)Vision coveage(if offeed)

T chi v:Declined for:

oBn thn / Selfo(Cc) con / Child(en)oNgi Phi Ng/DP

Spose/DP

oBn thn/ Selfo(Cc) con / Child(en)oNgi Phi Ng/DP

Spose/DP


Spose/DP

L do t chi: (c th cn n bng chng bo him)Reason for declining: (proof of coverage may be required)

oc bo him bi chng tnh theo nhm c ti t bi nh tyn dng ca ngi phing/bn sng chng;Coveed by sposes/domestic patnes sponsoed gop plan;Tn cng ty bo him / Caie name: _____________________________________________S ID / ID#: ______________________

oc Bo Him bi n Bo Him C Nhn; / Coveed by Individal Policy;Tn cng ty bo him / Caie name: _____________________________________________S ID / ID#:______________________

oc bo him bi Ticae / Coveed by Ticaeoc bo him bi Medicae / Coveed by Medicae oMediCaloc bo him bi bt k chng tnh bo him no khc;

Enolled in any othe insance plan;Tn cng ty bo him / Caie name: _____________________________________________S ID / ID#: ______________________

oKhc / Othe:_________________________________________________________________Bo him nhn th(n c gii thi)Life coveage(if offeed)


Spose/DP

S An Sinh X Hi hoc S ID caNgi Phi Ng/DPSpose/DP Social Secity o ID No.



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Ch k nu t chi bo him cho bn thn/ngi ph thuc

Signature if declining coverage for self/dependents

XNgy Thng Nm

(Thng/Ngy/NmDate (Month/Day/Ye

Ti xc nhn ng ti c cp tn ca mnh gii thch cc chng tnh bo him hin c v ti bit ng ti c yn ng k tham gia bo him. Ti c tokin ng k tham gia bo him ny v ti yt nh khng ng k cho bn thn v/hoc (nhng) ngi ph thc ca mnh, n c. Ti t ngyn a a yt nh nv khng c ai tm cch gy nh hng n ti hay to p lc cho ti khin ti t chi bo him. KHI T CHI BO HIM Y T THEO NHM NY (Tr PHI NHN VV/HOC NGI PH THuC C BO HIM Y T THEO NHM NI KHC), TI BIT rNG NHNG NGI PH THuC CA TI V TI C TH PHI CN MI HAI (12) THNG C NG K THAM GIA CHNG TrNH BO HIM Y T V/HOC NHN TH THEO NHM NY, cng nh khong thiloi t s thng do bnh tng c tc Tr KHI C CHO THI GIAN NG K C BIT V NHNG HON CNH THAY I NHT NH (V D NH, VMT NGI PH THuC MuA C HOC MT BO HIM KHC V MT NGI PH THuC. S khng p dng khong thi gian ch mi hai (12) thng (1) Ti xc nhn vo thi im ng k ban ng bo him theo mt chng tnh phc li y t ca nh tyn dng khc, mt chng tnh bo him y t dnh chem ca ti bang, hoc chng tnh Medicaid ca ti bang l l do ca vic t chi ng k v ti mt khon bo him theo chng tnh yn li y t ca nh tdng , mt chng tnh bo him y t dnh cho t em ca ti bang, hoc mt chng tnh Medicaid ca ti bang; (2) cp tn ca ti gii thi nhi chng phc li y t v ti chn mt chng tnh khc tong thi gian cho php ng k; (3) mt ta n a lnh cho ti phi cng cp khon bo him theo chng tnhcho mt ngi phi ng hoc a con nh hoc (4) n ti c mt ngi ph thc mi do hn nhn, sinh con, nhn con ni hoc b t nhn con ni, h c th ng k n phi ng k tong vng 31 ngy sa khi kt hn, sinh con, nhn con ni hoc b t nhn con ni.I acknowledge that the available coveages have been explained to me by my employe and I know that I have evey ight to apply fo coveage. I have been given thechance to apply fo this coveage and I have decided not to enoll myself and/o my dependent(s), if any. I have made this decision volntaily, and no one has tied toinflence me o pt any pesse on me to decline coveage. BY DECLINING THIS GrOuP MEDICAL COVErAGE (uNLESS EMPLOYEE AND/Or DEPENDENTSHAVE GrOuP MEDICAL COVErAGE ELSEWHErE) I ACKNOWLEDGE THAT MY DEPENDENTS AND I MAY HAVE TO WAIT uP TO TWELVE (12) MONTHS TO BENrOLLED IN THIS GrOuPSMEDICAL AND/Or GrOuP LIFE INSurANCE PLAN, as well as a six-month pe-existing condition exclsion uNLESS ENTITLED TO

A SPECIAL ENrOLLMENT PErIOD DuE TO CErTAIN CHANGED CIrCuMSTANCES (E.G., ACquISITION OF A DEPENDENT Or LOSS OF OTHEr COVErAGETHrOuGH A DEPENDENT. The twelve (12) month wait will not apply if: (1) I cetify at the time of initial enollment that the coveage nde anothe employe health beplan, a state child health insance pogam, o a state Medicaid plan was the eason fo declining enollment and I lose coveage nde that employe health benefitplan, a state child health insance pogam, o a state Medicaid plan; (2) my employe offes mltiple health benefit plans and I elected a diffeent plan ding an openenollment peiod; (3) a cot odes that I povide coveage nde this plan fo a spose o mino child o (4) if I have a new dependent as a eslt of maiage, bith,adoption o placement fo adoption, they may be able to be enolled if enollment is eested within 31 days afte the maiage, bith, adoption o placement fo adoptiN ti t chi ng k cho bn thn v/hoc (nhng) ngi ph thc ca mnh (k c ngi phi ng/bn sng chng ca ti) v bo him y t hoc bo him chng tnh chm sc sc khe theo nhm khc theo chng tnh bo him y t dnh cho t em ca ti bang, hoc mt chng tnh Medicaid ca ti bang, tiy c ng k tong vng 31 ngy sa khi khon bo him khc kt thc (hoc sa khi nh tyn dng ngng ng ph cho khon bo him kia).

If I declined enollment fo myself and/o my dependent(s) (inclding my spose/domestic patne) becase of othe health insance o gop health plan coveage exccoveage nde a state child health insance pogam, o a state Medicaid plan, I mst eest enollment within 31 days afte the othe coveage ends (o afte theemploye stops contibting towad the othe coveage).N ti t chi ng k cho bn thn v/hoc (nhng) ngi ph thc ca mnh (k c ngi phi ng/bn sng chng ca ti) v khon bo him theo chng tnh

him y t dnh cho t em ca ti bang, hoc mt chng tnh Medicaid ca ti bang, ti phi y c ng k tham gia bo him theo nhm ny tong vng 60 n(a) sa ngy khon bo him ca ti theo cc chng tnh ny kt thc; hoc (b) sa ngy ti ti chn nhn s h t ph bo him ca ti bang cho khonhim theo nhm.

If I declined enollment fo myself and/o my dependent(s) (inclding my spose/domestic patne) becase of coveage nde a state child health insance pogam,state Medicaid plan, I mst eest enollment fo this gop coveage within 60 days: (a) afte the date my coveage nde any of these plans ends; o (b) afte the dbecome eligible fo state pemim assistance fo gop coveage.Vui lng tm hiu cc la chn ca qu v mt cch cn thn trc khi t chi bo him ny. Qu v nn lu rng cc cng ty bn bo him y t c nhn thyu cu xem xt h s bnh n ca qu v, vic c th dn n ph bo him cao hn hoc qu v c th b t chi bo him hon ton.

Please examine your options carefully before declining this coverage. You should be aware that companies selling individual health insurance typically reqa review of your medical history that could result in a higher premium or you could be denied coverage entirely.

S An Sinh X Hi hoc S ID Ngi Phi Ng/DPSpose/DP Social Secity o ID


*MCAFR1167CEV 3/09 05MCAFr1167CEV 3/0

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C bt k ai c tn trong n ng k ny tng, tham vn , tm kim bin php iu tr, c ngh iu tr, c iu tr, ciu tr phu thut hoc c nhp vin v bt k bnh trng no sau y hay khng?

Has any person listed on this application ever had, consulted for, sought treatment, had treatment recommended, received treatment, beensurgically treated or been hospitalized for any of the following conditions?

1. Nhi m c tim, tim p bt thng, t , a ngc, cao hyt p, thi m, gin tnh mch, hoc bt k i lonno khc v tim, m, mch m, tng lipid hyt hoc x cng ng mch?Heat attack, heat mm, stoke, chest pain, high blood pesse, anemia, vaicose veins, o any othe disode ofthe heat, blood, blood vessels, hypelipemia o ateioscleosis? ........................................................ ...............................oC / Yes oKhng / No

2. Lot, vim kt tng, si mt, thot v hoc bt k i lon no v d dy, t, tc tng, ti mt, hoc gan?ulce, colitis, gall stone, henia o any othe disode of the stomach, intestines, ectm, gall bladde, o live? ...............oC / Yes oKhng / No

3. ung th, nang, hoc khi ? / Cance, cyst, o tmo? ............................................................ ............................................oC / Yes oKhng / No

4. ri lon v thn, m hoc albmin, tyn gip, bnh ti ng, bnh hoa li hoc bt k i lon no lin ann mt, h tit ni, c an sinh dc nam hoc n, hoc i lon kinh ngyt?Disode of the kidneys, blood o albmin, thyoid glands, diabetes, veneeal disease o any elated eye disodes,inay systems, male o female ogans, o menstal dysfnction? ................................................................................... oC / Yes oKhng / No

5. Bnh lao, syn, st ma h, si vm hng, vim mng phi hoc bt k i lon no lin an n phi hoc h h hp?Tbeclosis, asthma, hay feve, adenoids, pleisy o any othe disode of the lngs o espiatoy system? .................oC / Yes oKhng / No

6. ng kinh, cc cn bt tnh, bnh tm thn hoc thn kinh, lit hoc bt k i lon no v no hoc h thn kinh?Epilepsy, fainting spells, mental o nevos condition, paalysis o any disode of the bain o nevos system? .............oC / YesoKhng / No

N l ng kinh, ngy xt hin cn ng kinh ci cng / If epileptic, date of last seize: ______ /______ /______

7. c i t chng nghin hoc lm dng ma ty hoc dc cht khc hoc c t vn cch i t cngnhng chng bnh ?Been teated fo alcoholism o othe dg o sbstance abse o been advised to seek teatment fo the same? .............oC / YesoKhng / No

8. Vim khp, st thp khp, a lng, hoc bt k i lon no khc v khp, c, hoc xng?Athitis, hematic feve, back toble, o any othe disode of the joints, mscles, o bones? ........................................ oC / YesoKhng / No

9. Bt k khim khyt hoc bin dng hnh th no? Bt k thng tn c th, gy nt, chn ng no, phng, v/hoccc bnh tng bm sinh?

Any physical defomity o defect? Any seios bodily injy, facte, concssion, bn, and/o congenital poblems? .....oC / YesoKhng / No10. C bt k ai c bo him tng hoc c cho bit h mc mt chng i lon sy gim min dch, AIDS, hoc

phc hp lin an n AIDS, bt k kt xt nghim HIV?Has any peson to be coveed had o been told that they had an immne deficiency disode, AIDS, o AIDS-elatedcomplex, not inclding the eslts of HIV testing? ........................................................ ........................................................oC / YesoKhng / No

11. Tong vng 12 thng va a, tng ng thc theo toa ca mt bc s hoc nhn vin y t khc?Within the last 12 months, taken medicine as pescibed by a physician o othe health pactitione? ..............................oC / YesoKhng / No

5. Bng Cu Hi v Sc Khe dnh cho Nhn Vin ng K Theo Nhm 1-10 cp trn ca qu v s khng bithoc nhn c thng tin mt nyHealth Questionnaire for Groups Enrolling 1-10 Employees this confidential information will not be seen orgiven to your employer

Cc m c 11-50 n Vi g K: Khng in vo mc ny. Vui lng b qua n Mc 5A.Groups wit 11-50 Erollig Employees: Do not complete this section. Please skip to Section 5A. Tt c cc cu i pi c tr li l "C" oc "Kg".

n nG K ChA hOn Chnh S C TR LI QU V In Y , IU nY C Th LM ChM nGY BO hIM ChIU LC CA QU V.

All questios must be aswered Yes or no.InCOMPLETE APPLICATIOnS WILL BE RETURnED TO YOU FOR COMPLETIOn WhICh MAY DELAY ThE EFFECTIVE DATE OF YOURCOVERAGE.


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12 a. C bt k ph n no c bo him hin ang mang thai khng? Is any female to be coveed cently pegnant? .......................................................... .................................................. oC / YesoKhng N c, Ngy D Kin sinh / If yes, De Date: ______ /______ /______

b. N v l nam c tn tong n ng k ny, v c d nh sinh con vi bt k ai khng, thm ch ngi mkhng c tn tong n ng k ny?

If yo ae a male listed on this application, ae yo expecting a child with anyone, even if the mothe is not listed onthis application?................................................................................................................................................................ oC / YesoKhng

13. C bt k ai c tn tong n ng k ny s dng cc sn phm thc l khng? Does anyone listed on this application se tobacco podcts? .......................................................................................... oC / YesoKhng

Nu qu v tr li "C" i vi tt c hoc mt phn cc cu hi 1-12b bn trn, vui lng in thng tin sau y (C tm trag u cIf you answer Yes to all or part of above questions 1-12b, please complete the following (Isert additioal seets if ecessary):

C hi # / qestion #___ C hi # / qestion #___

Tn ca bnh nhn / Name of patient__________________________ Tn ca bnh nhn / Name of patient _______________________

Bnh tng c i t / Condition teated_____________________ Bnh tng c i t / Condition teated__________________

Ngy i t / Dates of teatment: Ngy i t / Dates of teatment:

Bt / Stat ____________________Kt thc / End___________ Bt / Stat ___________________ Kt thc / End ________

Bin php i t c thc hin / Teatment endeed___________ Bin php i t c thc hin / Teatment endeed_________

Thc v li dng c s dng / Medication and dosage taken Thc v li dng c s dng / Medication and dosage taken

________________________________________________________ _____________________________________________________

Ngy s dng / Dates taken: Ngy s dng / Dates taken:

Bt / Stat________ ____________Kt thc / End ___________ Bt / Stat ____________________ Kt thc / End ________

C hi # . qestion #___ C hi # / qestion #___

Tn ca bnh nhn / Name of patient__________________________ Tn ca bnh nhn / Name of patient _______________________Bnh tng c i t / Condition teated_____________________ Bnh tng c i t / Condition teated __________________


Bt / Stat ____________________Kt thc / End___________ Bt / Stat ___________________ Kt thc / End ________

Bin php i t c thc hin / Teatment endeed___________ Bin php i t c thc hin / Teatment endeed_________


________________________________________________________ _____________________________________________________


Bt / Stat________ ____________Kt thc / End ___________ Bt / Stat _____________________ Kt thc / End ________

nh d y n vn ang c i to nh d y n vn ang c i t check hee if still nde teatment check hee if still nde teatmen

nh d y n vn ang c i to nh d y n vn ang c i t check hee if still nde teatment check hee if still nde teatmen

nh d y n vn ang dng thco nh d y n vn ang dng thc check hee if still taking check hee if still taking


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Sau khi in y , vui lng tho bng v gp li nim phong.After completion, please remove tape and fold closed to seal.


C bt k ai c tn trong n ng k ny / Has any person listed on this application:

1. Tng tham vn, c i t, c t vn i t, hoc c i t hoc nhp vin v bt k bnh tng no sa y:Eve had, conslted fo, had teatment endeed, been advised to have teatment, o eceived teatment o beenhospitalized fo any of the following conditions:

B tim mc oc i mu c tim; t qu; ri lo t, d dy, rut oc ga; cc b trg v c - xg;b tm t oc t ki; cc ri lo t ki trug g; b tiu g; bt k ri lo o pi oc p; ug t oc ri lo suy gim mi dc, AIDS, oc pc p li qua AIDS, bt k kt qu xt

gim hIV?Cardiovascular disease or eart attack; stroke; disorder of te kidey, stomac, itesties or liver; musculoskeletalcoditios; metal or ervous coditio; cetral ervous system disorders; diabetes; ay disorder of te lugs orrespiratory system; cacer or immue deficiecy disorder, AIDS, or AIDS-related complex, ot icludig te results ofhIV testig? .......................................................................................................................................................................... oC / YesoKhng / No

2. Tong 24 thng va a, c c ph tht hoc phi nm vin, vin i dng, c s phc hihoc c s chm sc chyn s hoc c chi ph y t tn $5.000 khng? Ding the last 24 months, had sgey o been confined in any hospital, sanitaim, convalescent facilityo specialized cae facility o had medical expenses moe than $5,000? ........................................................... ................oC / YesoKhng / No

3. Tong vng 12 thng va a, tng ng thc theo toa ca mt bc s hoc nhn vin y t khc?Within the last 12 months, taken medicine as pescibed by a physician o othe health pactitione? ............................. oC / YesoKhng / No

4. a. C bt k ph n no c bo him hin ang mang thai khng?Is any female to be coveed cently pegnant? ..............................................................................................................oC / YesoKhng / No

N c, Ngy D Kin sinh / If yes, De Date: ______ /______ /______

b. N v l nam c tn tong n ng k ny, v c d nh sinh con vi bt k ai khng, thm ch ngi mkhng c tn tong n ng k ny?If yo ae a male listed on this application, ae yo expecting a child with anyone, even if the mothe is not listed onthis application? ............................................................... ............................................................... ....................................oC / YesoKhng / No

5. C bt k ai c tn tong n ng k ny s dng cc sn phm thc l khng?Does anyone listed on this application se tobacco podcts? ............................................................... ............................ oC / YesoKhng / No

5A. Bng Cu Hi v Sc Khe dnh cho Nhn Vin ng K Theo Nhm 11-50 cp trn ca qu v s khng bithoc nhn c thng tin mt ny

Health Questionnaire for Groups Enrolling 11-50 Employees this confidential information will not be seen orgiven to your employer

Cc m c 1-10 n Vi g K: Khng in vo mc ny; qu v ch phi in mc trc.Groups wit 1-10 Erollig Employees: Do not complete this section; you are only required to complete the

previous section.

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nh d y n vn ang c i to nh d y n vn ang c i t check hee if still nde teatment check hee if still nde teatment


nh d y n vn ang c i to nh d y n vn ang c i t check hee if still nde teatment check hee if still nde teatment


Nu qu v tr li "C" i vi tt c hoc mt phn cc cu hi 1-4b bn trn, vui lng in thng tin sau y (C tm trag u If you answer Yes to all or part of the above questions 1-4b, please complete the following (Isert additioal seets if ecessary):


Tn ca bnh nhn / Name of patient__________________________ Tn ca bnh nhn / Name of patient ______________________

Bnh tng c i t / Condition teated_____________________ Bnh tng c i t / Condition teated _________________


Bt / Stat ____________________Kt thc / End___________ Bt / Stat ___________________ Kt thc / End _______

Bin php i t c thc hin / Teatment endeed___________ Bin php i t c thc hin / Teatment endeed________


________________________________________________________ ____________________________________________________


Bt / Stat ____________________Kt thc / End___________ Bt / Stat _____________________ Kt thc / End _______


Tn ca bnh nhn / Name of patient __________________________ Tn ca bnh nhn / Name of patient ______________________

Bnh tng c i t / Condition teated_____________________ Bnh tng c i t / Condition teated _________________


Bt / Stat ____________________Kt thc / End___________ Bt / Stat ___________________ Kt thc / End _______

Bin php i t c thc hin / Teatment endeed___________ Bin php i t c thc hin / Teatment endeed________


________________________________________________________ ____________________________________________________


Bt / Stat________ ____________Kt thc / End ___________ Bt / Stat _____________________ Kt thc / End _______


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6. Bo Him Khc vui lng m bo in y thng tin quan trng ny: Other Coverage please be sure to complete this important information:

1. C bt k ai c tn tong n ng k ny c nh tip tc tham gia bo him theo Nhm khc n n ng k ny c chp nhn haykhng?

Do any pesons on this application intend to contine othe Gop coveage if this application is accepted? .........oC / YesoKhng / No N c / If yes:

Tn ca ngi / Name of peson: __________________________________________________________________________________

Cng Ty Bo Him / Insance Company: ______________________________________________________________________________

2. C bt k ai ng k tham gia bo him tng tham gia bo him y t vo bt k thi im no tong s thng va a hay khng?Has any peson applying fo coveage had health insance coveage at any time in the past six months? ...........oC / YesoKhng / No

N c / If yes:Tn ca ngi ng k/thnh vin gia nh / Applicant/family membe name(s): ________________________________________________

Loi bo him / Type of coveage: oNhm / Gop oC nhn / Individal oKhc / Othe: _________________________________


Ngy bo him bt c hi lc / Date coveage began: ___________________ Ngy kt thc / Date ended:____________________

3. C bt k ai ng k tham gia bo him hin nay c bo him nha khoa hay khng?Does any peson applying fo coveage cently have dental insance coveage?................................................oC / YesoKhng / No

N c / If yes:Tn ca ngi ng k/thnh vin gia nh / Applicant/family membe name(s): ________________________________________________

Loi bo him / Type of coveage: oNhm / Gop oC nhn / Individal oKhc / Othe: _________________________________


Ngy bo him bt c hi lc / Date coveage began: ____________________ Ngy kt thc / Date ended:____________________

4. C bt k ai ng k nhn khon bo him ti chn tham gia Medicae hoc hin ang nhn cc khon phc li Medicae hay khng?Is any peson applying fo coveage eligible fo Medicae o cently eceiving Medicae benefits?.......................oC / YesoKhng / No

LU : N v ti chn tham gia Medicae, Anthem Ble Coss c th khng nhn i cc yn li ca Medicae.NOTE: If yo ae eligible fo Medicae, Anthem Ble Coss may not dplicate Medicae benefits.

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NP CHNG MINH KHON BO HIM. / SUBMIT PROOF OF COVERAGE. tun th lut php lin bang v tiu bang, ti liu chng minh bo him ny phi c gi km n ng k ny. To comply with federal and state laws, proof of this coverage must accompany this application.

Cc hnh thc chng minh c chp nhn l / Acceptable forms of proof are:

1. Chng nhn bo him ca cng ty bo him tc y, hocCetificate of coveage fom pio caie, or

2. Bn sao th ID v bn sao cng bin nhn tin lng cho bit khon kh t bo him y t, hocCopy of ID cad and copy of payoll stb showing medical coveage dedction, or

3. Bn sao ha n ph bo him y t mi nhtCopy of most ecent medical pemim bill

Vui lng lu : Nu qu v hoc mt thnh vin gia nh c/ c mt bnh trng trc khi n vi chng trnh ca chng ti trong c t vn y khoa, chn on, c ngh hay c iu tr hoc chm sc trong vng su thng va qua v qu v khngthng bo v cung cp chng minh khon bo him trc , qu v c th b loi tr do bnh trng c trc trong su thng (khngp dng i vi cc chng trnh HMO).iu c ngha l u v c th phi i t nht su thng trc khi chng trnh cungcp bo him cho bnh trng (khng p dng i vi vic mang thai hoc i vi mt a tr c ng k tham gia ch

trnh trong vng 31 ngy sau khi sinh, nhn con nui hoc b tr nhn con nui). Trong mt s trng hp, khong thi gian lotr c th ko di n 12 thng, hoc ln n 18 thng i vi ngi ng k tr. Tuy nhin, thi gian ch c th c gim ts ngy ca "chng trnh bo him c uy tn" trc , c ngha l khng c gin on trong bo him y t tiu chun tr ko di trn 63 ngy i vi mt chng trnh C Nhn hoc 180 ngy i vi mt chng trnh do nh tuyn dng ti trhoc lin uan n nh tuyn dng. Cn c ti liu chng minh bo him c uy tn gim thi gian ch, k c mt bn sao chng nhn hoc cc ti liu khc, m chng ti c th gip u v c c nhng ti liu ny t mt chng trnh/ngi cptrc nu cn. qu v c uyn nhn c ti liu chng minh bo him c uy tn t chng trnh/ngi cp trc camnh. Vui lng lin h vi [Small Group Enrollment & Billing Services] (B Phn ng K Nhm Nh & Lp Ha n) ca chti ua s [1-800-627-8797] nu u v c bt k thc mc no lin uan n cc bnh trng c trc.Please note: If you or a family member have/had a medical condition before coming to our plan for which medical advice, diagnosis, caor treatment was recommended or received within the last six months and you do not advise and provide proof of prior coverage, youmay be subject to a six-month preexisting condition exclusion (does not apply to HMOs). That means that you might have to wait atleast six months before the plan will provide coverage for that condition (does not apply to pregnancy nor to a child who is enroin the plan within 31 days after birth, adoption or placement for adoption). In some cases, the exclusion may last up to 12 monor as long as 18 months for late enrollees. However, the length of the waiting period can be reduced by the number of days ofprior creditable coverage, which means not experiencing a break in ualified prior health coverage that lasted more than 63 dfor an Individual plan or 180 days for an employer-sponsored or employer-related plan. Proof of creditable coverage is reuiredto reduce a waiting period, including a copy of the certificate or other documentation, which we can help you obtain from a prioplan/issuer if needed. You have the right to obtain proof of creditable coverage from your prior plan/issuer. Please contact our [SGroup Enrollment & Billing Services] at [1-800-627-8797] if you have any uestions regarding preexisting conditions.


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7. Tha Thun v Xc Nhn - Bn Tha Thun sau y s c NHN VIN ng k tham gia bo him k vo. Agreements and Understandings - The following Agreement is to be signed by the EMPLOYEE applying for

coverage.TI NG : Vi tt c hi bit ca ti, mi thng tin tong m n ny l chnh xc v tng thc. Ti hi ng n ng k ny v bt k thngtin no m Anthem Ble Coss v/hoc Anthem Ble Coss Life and Health Insance Company c c tc ngy bo him c hi lc l c s bo him c cp theo chng tnh ny. Ti ng cho php cp tn ca ti tch ng bo him t khon th nhp ca mnh (n c) thanhton chi ph ca chng tnh ny. Ti xc nhn ng ti ang lm vic ti a im kinh doanh ca cp tn ca ti v t cng vic l di.I AGREE: To the best of my knowledge and belief, all infomation on this fom is coect and te. I ndestand that this application and anyinfomation Anthem Ble Coss and/o Anthem Ble Coss Life and Health Insance Company obtains pio to the effective date of coveageis the basis on which coveage may be issed nde the plan. I athoize my employe to dedct fom my eanings the contibtion (if any)eied to apply towad the cost of this plan. I cetify that I am woking at my employes place of bsiness in pemanent employment.

Ti hi ng n ng k ca cp tn ca ti s yt nh khon bo him v ng khng c bo him no t phi v cho n khi n ngk ny v bt k n ng k no do cp tn ca ti lp c chp nhn v ph dyt bi ANTHEM BLuE CrOSS v/hoc ANTHEM BLuECrOSS LIFE and HEALTH INSurANCE COMPANY.

I ndestand that my employes application will detemine coveage and that thee is no coveage nless and ntil this application and anyapplication made by my employe have been accepted and appoved by ANTHEM BLuE CrOSS and/o ANTHEM BLuE CrOSS LIFE andHEALTH INSurANCE COMPANY.

TI NG K NHN BO HIM PPO: Ti hi ng ti ch tch nhim thanh ton phn chi ph y t ln hn ca mnh khi ti s dng mt nhcng cp ngoi h thng. N chn mt Chng Tnh PPO v s dng mt nh cng cp ngoi h thng, th cc khon thanh ton y t s datn phn tm t hn tong bi ph thng lng v ti s ch tch nhim thanh ton bt k khon no vt khon thanh ton .I AM APPLYING FOR PPO COVERAGE: I ndestand that I am esponsible fo a geate potion of my medical costs when I se anonpaticipating povide. If a PPO Plan is selected and a nonpaticipating povide is sed, medical payments will be based pon the lessepecentage of the negotiated fee ate and I will be esponsible fo any amont ove that payment.

TI NG K THAM GIA BO HIM HMO: Ti hi ng ti ch tch nhim thanh ton cc dch v c cng cp m khng c nhm yt chnh ca ti cho php.

I AM APPLYING FOR HMO COVERAGE: I ndestand that I am esponsible fo paying fo sevices endeed that ae not athoized by mypimay medical gop.

TI NG K THAM GIA CHNG TRNH EPO THCH HP TI KHON TIT KIM CHM SC SC KHE (HEALTHCARE SAVINGSACCOUNT, HSA): Ti hi ng Chng Tnh High Dedctible EPO c thit k s dng T Chc Cng Cp c qyn (ExclsivePovide Oganization, EPO), v vic s dng cc nh cng cp ngoi h thng c th dn n cc khon chi ph pht sinh cao hn ngk.-- Ti hi ng vic c khon bo him ny khng to a mt HSA. thc hin vic , ti phi lin h vi mt t chc tn dng tichn. Ngoi a, ti hi ng ti nn tham kho kin ca c vn th ca mnh.

I AM APPLYING FOR A HEALTHCARE SAVINGS ACCOUNT (HSA) COMPATIBLE EPO PLAN: I ndestand that the High Dedctible EPOPlan is designed fo Exclsive Povide Oganization (EPO) sage, and that sing nonpaticipating povides cold eslt in significantlyhighe ot-of-pocket costs. I ndestand that having this coveage does not establish an HSA. To do so, I mst contact a alified financialinstittion. Also, I ndestand that I shold conslt my tax adviso.

NGHIM CM XT NGHIM HIV: Lut php California nghim cm vic cc cng ty bo him y t yu cu hoc s dng xt nghimHIV lm iu kin nhn bo him y t.HIV TESTING PROHIBITED: California law prohibits an HIV test from being required or used by health insurance companies as acondition of obtaining health insurance.HY B HOC IU CHNH BO HIM. VUI LNG C K.Ti xc nhn ng khi k tn di y ti xem li cc thng tin c cng cp tong n ng k ny v ng vi cc i khon tong l ikin nhn bo him. Ti tyn b cc c t li cho tt c cc c hi tong n ng k ny l ng s thc v chnh xc vi tt c hi bit ca tiv ti hi ng nhng c t li ny s c dng lm cn c Anthem Ble Coss v/hoc Anthem Ble Coss Life and Health Insance Companychp nhn n ng k ny. Ti hi ng vic khai bo sai hoc khng bo co thng tin y t mi tc ngy c hi lc c th dn n s thay ian tng hoc ph bo him. Vic khai bo sai thc t hoc thi st ng k tong n ng k ny c th dn n ph bo him tng, cc yn

li b t chi hoc (cc) khon bo him b hy b. Ti hi ng Anthem Ble Coss v/hoc Anthem Ble Coss Life and Health Insance Companyc th hy bt k bo him no theo n ng k ny v bt k l do no sa y: (a) bt k s khai bo sai an tng c pht hin tong n ngk hoc bo co y t; v/hoc (b) c hnh vi gian ln.CANCELLATION OR MODIFICATION OF COVERAGE. PLEASE READ CAREFULLY.I attest by signing below that I have eviewed the infomation povided on this application and accept its povisions as a condition of coveage. I epesentthat the answes given to all estions on this application ae te and accate to the best of my knowledge and belief and I ndestand they will be eliedpon by Anthem Ble Coss and/o Anthem Ble Coss Life and Health Insance Company in accepting this application. I ndestand that misstatementso failes to epot new medical infomation pio to the effective date may eslt in a mateial change o pemim. Mateial misepesentations osignificant omissions in this application may eslt in inceased pemims, benefits being denied o coveage(s) being cancelled. I ndestand thatAnthem Ble Coss and/o Anthem Ble Coss Life and Health Insance Company may cancel any coveage nde this application de to any of thefollowing: (a) any mateial misepesentation discoveed on an application o health statement; and/o (b) an act of fad that has been committed.

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Sau khi in y , hy tho bng cc trang bn trong, gp li nim phong, v np n ng k cho cp trn ca qu v.n ng k cha hon chnh s c gi li qu v in y . iu ny c th lm chm ngy bo him c hiu lc ca qu v.After completion, remove tape on inside pages, fold closed to seal, and submit application to your employer.Incomplete applications will be mailed back to you for completion. This may delay the effective date of your coverage.

Cc chng tnh chm sc sc khe do Anthem Ble Coss cng cp. Cc chng tnh bo him doAnthem Ble Coss Life and Health Insance Company cng cp. Anthem Ble Coss l thng hica Ble Coss. Nhng bn c cp php c lp ca Ble Coss Association. ANTHEM l thnghi ng k ca Anthem Insance Companies, Inc. Tn v bi tng The Ble Coss l nhn hing k ca Ble Coss Association.

Health cae plans povided by Anthem Ble Coss. Insance plans povided by Anthem Ble CossLife and Health Insance Company. Anthem Ble Coss is the tade name of Ble Coss. Independentlicensees of the Ble Coss Association. ANTHEM is a egisteed tademak of Anthem InsanceCompanies, Inc. The Ble Coss name and symbol ae egisteed maks of the Ble CossAssociation.

Cc Dch V Nhm NhAnthem Ble Coss[P.O. Box 9062Oxnad, CA 93031-9062]anthem.com/ca

Small Gop SevicesAnthem Ble Coss[P.O. Box 9062Oxnad, CA 93031-9062]anthem.com/ca

Vui Lng c K- Cn C Ch KPlease Read Carefully- SIGNATurE rEquIrEDYU CU TRNG TI RNG BUC / REQUIREMENT FOR BINDING ARBITRATIONTi hi ng n bo him ca ti c cng cp theo chng tnh yn li do mt nh tyn dng ti t c min min p dng o Lt Bom Th Nhp Khi V H Ca Ngi Lao ng (Employee retiement Income Secity Act, ErISA) nm 1974 hoc n ti c bt ng khng

nm tong y nh ca ErISA th ti s tn theo i khon v tng ti ng bc sa y.I ndestand that if my coveage is povided psant to an employe-sponsoed benefit plan that is exempt fom Employee retiement IncomeSecity Act of 1974 (ErISA) o if I have a dispte that is not govened by ErISA that I will be sbject to the following binding abitation povision.

iu khon sau y khng p dng i vi cc t quyn tp th:The following provision does not apply to class actions:

NU QU V NG K THAM GIA BO HIM, VUI LNG LU RNG ANTHEM BLUE CROSS V ANTHEM BLUE CROSS LIFE ANDHEALTH INSURANCE COMPANY YU CU TRNG TI RNG BUC GII QUYT TT C CC BT NG BAO GM NHNG KHNGGII HN, CC BT NG LIN QUAN N VIC CUNG CP DCH V THEO CHNG TRNH/N BO HIM HOC BT K VN NO KHC LIN QUAN N CHNG TRNH/N BO HIM V CC KHIU NI V HNH NG Y KHOA PHI PHP, NU MC BTNG VT QU GII HN THM QUYN CA TA N NH X L N KHIU NI.iu ny cng c hiu rng bt k bt ng nok c nhng bt ng lin quan n vic cung cp dch v theo chng trnh/n bo him hoc bt k vn no khc lin quan nchng trnh/n bo him, bao gm bt k bt ng no nh i vi hnh ng y khoa phi php, c ngha l, d bt k dch v y t no

c cung cp theo hp ng ny l khng cn thit hoc khng c php hoc khng thch hp, c cung cp khng chu o hockhng hon chnh, s c xc nh bng vic trnh ln trng ti theo quy nh ca lut php bang California, v khng theo mt vkin hoc s dng quy trnh ta n tr khi lut php bang California quy nh v vic xem xt phn x cc v kin trng ti. Vi vic kkt hp ng ny, c hai bn trong hp ng ny t b quyn hp php ca mnh a bt k tranh chp no nh vy n mt ta nquyt nh trc mt bi thm on, v thay vo chp nhn s dng trng ti. IU NY C NGHA L QU V V ANTHEM BLUECROSS V/HOC ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY KHC T QUYN XT X TRC BI THMON I VI C KHIU NI V HNH NG Y KHOA PHI PHP, V BT K BT NG NO KHC K C NHNG BT NGLIN QUAN N VIC CUNG CP DCH V THEO CHNG TRNH/N BO HIM HOC BT K VN NO KHC LIN QUANN CHNG TRNH/N BO HIMIF YOU ARE APPLYING FOR COVERAGE, PLEASE NOTE THAT ANTHEM BLUE CROSS AND ANTHEM BLUE CROSS LIFE AND HEALTHINSURANCE COMPANY REQUIRE BINDING ARBITRATION TO SETTLE ALL DISPUTES INCLUDING BUT NOT LIMITED TO DISPUTESRELATING TO THE DELIVERY OF SERVICE UNDER THE PLAN/POLICY OR ANY OTHER ISSUES RELATED TO THE PLAN/POLICY ANDCLAIMS OF MEDICAL MALPRACTICE, IF THE AMOUNT IN DISPUTE EXCEEDS THE JURISDICTIONAL LIMIT OF SMALL CLAIMS COURT. Itis understood that any dispute including disputes relating to the delivery of services under the plan/policy or any other issues related to theplan/policy, including any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract wereunnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration asprovided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitrationproceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decidedin a court of law before a jury, and instead are accepting the use of arbitration. THIS MEANS THAT YOU AND ANTHEM BLUE CROSSAND/OR ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY ARE WAIVING THE RIGHT TO A JURY TRIAL FOR BOTH MEDICAL MALPRACTICE CLAIMS, AND ANY OTHER DISPUTES INCLUDING DISPUTES RELATING TO THE DELIVERY OF SERVICEUNDER THE PLAN/POLICY OR ANY OTHER ISSUES RELATED TO THE PLAN/POLICY.

Saukhiiny,hythobngcctrangbntrong,gplinimphong,v

npnngkchocptrncaqu

v.

Aftercompletion,

removetapeoninsidepage

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foldclosedtoseal,andsubmitapplic

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X

Ch K ca Nhn Vin (Bt Buc) Ngy Thng Nm(MM/DD/YY)Signate of Employee (Required) Date (MM/DD/YY)

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Anthem Blue Cross Life and Health Insurance CompanyNotice of Language Assistance

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Anthem Blue Cross

Language Assistance Notice

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