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^ Yes ~] No <br />O Yes 1'Cl Nc ,,, .,,o Nos~,v u,vmns, nos any creditor filed or threatened to file a petition requesting the Group/Company or any affiliated entity be <br />placed voluntarily into bankruptcy) <br />O Yes $7 No is your group a Professional Employer Organization (PEO) or Employee Leasing Company (ELC), or other such entity <br />that is a co-employer with your client(s) of client-site employee(s)? <br />If you answered Yes, then by signing this application you agree with the cerYrfication in this section. <br />hereby certify that my company is a PEO, ELC or other such entity and that only those employees that are the corparate employees of <br />my company, and not my co•employees, are permitted to enroll in this group policy. If my group at any point after l sign this application <br />determines that the group will provide coverage to the co-employees under the group's plan, I understand that UnitedHealthcare will <br />not cover the co-employees under this group policy. <br />What is your administrative policy regarding termination of eligibility for bane}Its related to your medical policy following a leave of absence? <br />(Please refer to the applicable state and federal rules that may require benefits to be provided for a specific length of time while an employee is on leave.) <br />^ Last Day worked (following the last day worked for the minimum hours required to be eligible} <br />^ 3 Months {following the last day worked for the minimum hours required to be eligible} <br />^ 6 Months (following the last day worked for the minimum hours required to be eligible} <br />^ UnitedHealthcare Policy Special Provisions Related to Medical Elfgibi(~ry* <br />~1 Qther(pleaseprovideacopyforaurrecords} (Last day o t e month after employee enters leave without pay status) <br />"UnltedHeafthcareSpacial Provisions Related to Medical Eligibility <br />If the employer continues to pay required medical premiums and continues participating under the medical policy, the covered person's coverage will remain <br />in force for: (1} No longer than 3 consecutive months if the employee is: temporarily laid•off; in part time status; or on an employer approved leave of absence. <br />(2} No longer than 6 consecutive months if the employee is totally disabled. <br />If this coverage terminates, the employee may exercise the rights under any applicable Continuation of Medical Coverage provision or the Conversion of <br />Medical Benefits provision described in the Certificate of Coverage. <br />do you currently otter or Intend to offer a Health Reimbursement Account {HRA} plan andler comprehensive supplemental insurance policy or funding <br />arrangement in addition to this UnitedHealthcare medical pfanT <br />Answers must be accurate whether purchased from UntedHealthcare orany other insurer or third party administrator. <br />HRA Yl Yes O No <br />if yos, please identify type: O UnitedHealthcare Definiry HRA (any HRA design offered through UnitedHealthcare) ^ Other Administrator HRA <br />HAA plans administered by other insurers or third perry administrators must complywith UnitedHealthcare HRA design standards. <br />Comprehensive Supplemental Insurance Policy or Funding Arrangement O Yes ^ No <br />If you answered °Yas' to either question above, you must choose from the list of UnitedHealthcare Definity HRA-eligible medical plans as shown to you by your <br />broker or agent. Other plans are not eligible for pairing with these arrangements. Purchase of such arrangements at any point during the duration of this <br />policy will require you to notify UnitedHealthcare. <br />nnn~ non nccvunr AammlStratOr: <br />Are there any other contributions or benefit reimbursements allowed? O Yes ;fc7 No <br />Who will provide account balances to UnitedHealthcare? n/a <br />In the past 36 months, has the Group/Company or any affiliated entity sled far protection or operated u der federal/state bankruptcy <br />Iaws7 (Chapter 7 or 11} <br />page 2 of <br />