United Healthcare Insured Employer Application

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The Group/Company certifies that the information provided above is complete and accurate. The Group/Company shall notify UnitedHealthcare and Affiliates promptly of any changes in this information that may affect the eligibility of employees or their dependents, including the addition of any newly eligible employees or dependents. Prior to receiving notification of approval, the Group/Company shall notify UnitedHealthcare and Affiliates promptly of any significant changes in the health status of an eligible employee or dependent including any inpatient hospital admissions. UnitedHealthcare and Affiliates shall tie entitled to rely on the most current information in its possession regarding the eligibility and health status of employees and their dependents in providing coverage under the policy/policies for which application is being made. I represent to the best of my knowledge the information I have furnished is accurate, and includes any employees and dependents who have elected continuation of insurance benefits. I understand that malarial omissions misrepresentations or misstatements in the information requested on this form can result in the adjustment of rating or voiding of insurance. i understand thstthe Certificate of Coverage or Summary Plan Description and other documents, notices and communications regarding the benefit plans} indicated herein on this Application may be transmitted electronically to me and to the Group's/Company's employees. Any person who knowingly and with intent to defraud any insurance company ar other person tales an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Upon receipt by UnitedHealthcare and Affiliates of this signed employer application and payment of the required policy charges, the group policy is deemed executed. The deposit check in the estimated amount of the first month's premium is not considered payment of the required policy charges. UnitedHealthcare disclosure regarding producer compensation: 'We pay brokers and agents (referred to collectively as'producers"}compensation for their services in connection with the sate of our insured products, in compliance with applicable law. We pay "base commissions' based on factors such as product type, amount of premium, group/company size and number of employees. These commissions are reflected in the premium rate. In addition, wa may pay bonuses pursuant to bonus programs established from time to time which are designed to encourage the introduction of new products and provide incentives to achieve production targets, persistency levels, growth goals or other objectives. Bonus expenses are not directly reflected in the premium rate but era included as part of the general administrative expenses. It is our policy not to pay commissions to producers with respect to a product for which the customer is also paying the producer a commission or other fee. Please note we also make payments from time to time to producers for services other than those relating to the sale of policies (for example, compensation for services as a genera! agent or as a consultant). Producer compensation is subject to disclosure on Schedule A of the ER1SA Form 5500 for customers governed by ERISA. We provide Schedule A reports to our customers as required by applicable federal law. We also have taken steps to ensure that producers property disclose their compensation arrangements to their customers, but we cannot guarantee the producer's compliance. Far general information on our producer payment arrangements, including the approximate percentage of total compensation that total bonus payments comprise, please go to httpJ/www.uhc.com and click on the drop down box for employers under'~ew Our Programs -Producer Payment Programs.' For specific information about the compensation payable with respect to your particular policy, please contact your producer. ~ Group/Company Signatur r' ~ Z ~ ~ ~ ~~ f~I D rue THIS DOCUMENT E p DO NOT CEt YO V THE ~>°~~ T~~~'~g~~~ ~ ~, FISCAL CONTROL ACT. Clarenee G. Grier, Financial Services Director ~~ ~ e Broker Name Agency Agent Code/Tax ID Number Signature Email Address SocialSecurity# PhaneNumber Oate Rep Name Rep # Commissions payable to Broker Commission Schedule Std Scale of % page 4 of 4