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Underwritten by Coventry Health Care of Iowa, Inc.

COVENTRY HEALTH CARE OF IOWA, INC.

Application for Health Coverage Important: Please print clearly in BLACK ink as instructed in each section. Initial and date corrections; correction fluid is not permitted. Read and sign the Acknowledgements Section. Check all that apply:

Submit completed Application for Health Coverage to: Coventry Health Care of Iowa, Inc. P.O. Box 31217 Tampa, FL 33631-3217 or email: [email protected] or by fax at: 1-877-904-7822

 New Application  Add a Dependent  Product Benefits Change  Child-Only Application (under 19 years old)  Qualifying Life Event (Only individuals experiencing a Qualifying Life Event are eligible for enrollment outside of the annual open enrollment period) Please list your Qualifying Life Event: _________________________________________________________

Product Choice Choose one (1) product only. If other individuals applying for coverage wish to apply for different products, a separate Application must be used. Gold

Silver

Bronze

Catastrophic

 Gold $5 Copay POS PD Plan

 Silver $10 Copay POS  Bronze $10 Copay POS PD Plan  Bronze Deductible Only POS PD HSA Eligible Plan PD Plan Carelink from Coventry Health Care Powered by Alegent Creighton Health1

 Catastrophic 100% POS PD Plan

 Gold $5 Copay HMO PD Alegent Creighton Health

 Silver $10 Copay HMO  Bronze $10 Copay HMO PD Alegent Creighton Health PD Alegent Creighton  Bronze Deductible Only HMO PD HSA Eligible Alegent Health Creighton Health Carelink from Coventry Health Care Powered by Methodist Health Partners1

 Catastrophic 100% HMO PD Alegent Creighton Health

 Gold $5 Copay HMO PD Methodist Health Partners

 Silver $10 Copay HMO PD Methodist Health Partners Carelink from Coventry Health Care Powered by MIPPA

 Bronze $10 Copay HMO PD Methodist Health Partners  Bronze Deductible Only HMO PD HSA Eligible Methodist Health Partners

 Catastrophic 100% HMO PD Methodist Health Partners

 Gold $5 Copay POS PD MIPPA

 Silver $10 Copay POS PD MIPPA Carelink from Coventry Health Care Powered by Patient Preferred

 Bronze $10 Copay POS PD MIPPA  Bronze Deductible Only POS PD HSA Eligible MIPPA

 Catastrophic 100% POS PD MIPPA

 Gold $5 Copay POS PD Patient Preferred

 Bronze $10 Copay POS PD Patient Preferred  Bronze Deductible Only POS PD HSA Eligible Patient Preferred

 Catastrophic 100% POS PD Patient Preferred

 Bronze $10 Copay POS PD UnityPoint Health – Cedar Rapids  Bronze Deductible Only POS PD HSA Eligible UnityPoint Health – Cedar Rapids  Bronze $10 Copay POS PD UnityPoint Health – Des Moines  Bronze Deductible Only POS PD HSA Eligible UnityPoint Health – Des Moines  Bronze $10 Copay POS PD UnityPoint Health – Quad Cities  Bronze Deductible Only POS PD HSA Eligible UnityPoint Health – Quad Cities  Bronze $10 Copay POS PD UnityPoint Health – Waterloo  Bronze Deductible Only POS PD HSA Eligible UnityPoint Health – Waterloo

 Catastrophic 100% POS PD UnityPoint Health – Cedar Rapids  Catastrophic 100% POS PD UnityPoint Health – Des Moines  Catastrophic 100% POS PD UnityPoint Health – Quad Cities  Catastrophic 100% POS PD UnityPoint Health – Waterloo

 Silver $10 Copay POS PD Patient Preferred

Carelink from Coventry Health Care Powered by UnityPoint Health  Gold $5 Copay POS PD UnityPoint Health – Cedar Rapids  Gold $5 Copay POS PD UnityPoint Health – Des Moines  Gold $5 Copay POS PD UnityPoint Health – Quad Cities  Gold $5 Copay POS PD UnityPoint Health – Waterloo

 Silver $10 Copay POS PD UnityPoint Health – Cedar Rapids  Silver $10 Copay POS PD UnityPoint Health – Des Moines  Silver $10 Copay POS PD UnityPoint Health – Quad Cities  Silver $10 Copay POS PD UnityPoint Health – Waterloo

Note: For the highest level of benefits, it’s important to use an in-network provider when you need care. 1 A Carelink participating provider must be used in order to receive benefits. Health Savings Account (HSA) Selection If you have selected a Bronze Deductible Only plan, you are eligible to open a Health Savings Account (HSA) through our HSA trustee, HealthEquity, upon approval.  I elect to have an HSA opened through HealthEquity Requested Effective Date The Effective Date will be assigned by Coventry based on the date of receipt of a completed application. ___ / ___ / _______ (mm/dd/yyyy)

Premium for the selected Product Choice: $_________ / Month  Individual  Family Note: This premium will only be effective for the current calendar year through December 31.

Primary Applicant Name: ______________________________ CHCIA-GSA-E-2014

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Agent Name: ____________________________________

Primary Applicant Information Please provide information on the Primary Applicant. If applying for Child-Only coverage, please fill in the parent or legal guardian’s information below. Last Name

First Name

MI

Home Address (not P.O. Box)

City

State

Zip

Mailing Address (If different from address above)

City

State

Zip

E-mail Address  Check here to consent to receiving your policy and other pertinent documents by e-mail only

County

Relationship (if Child-Only Application)

Phone Number  Home ( )

-

 Work

-

(

)

 Mobile ( )  If available, I would like to get information by Text.

 Check here to consent to receiving your Explanation(s) of Benefits (EOB) by e-mail  Check here to receive emails about tools and programs to help stay healthy  Check here to receive emails about tools, information and promotions to help manage health care costs and learn about new products Primary Language (if other than English):

 Spanish (Español)  Navajo (Dine)

 Chinese (中文)

 Tagalog (Tagalog)

 Other ____________________ Existing / Prior Insurance Coverage Does any individual applying for coverage currently have or had any health insurance coverage in the past 2 years? Effective Date

Termination Date

 Yes  No

Name of Persons Insured

Will the existing policy remain in effect?

 Yes  No

Does any individual applying for coverage currently have or had any dental insurance coverage in the past 2 years?

 Yes  No

Effective Date

Termination Date

Name of Persons Insured

Will the existing policy remain in effect?

Primary Applicant Name: ______________________________ CHCIA-GSA-E-2014

 Yes  No

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Agent Name: ____________________________________

Applicant and Dependent Information General Information List all individuals applying for health coverage in this section. For a Child-Only Application, begin listing child(ren) on Line 3 with the youngest child listed first. If you need more space, attach a separate sheet of paper with the details in the same format as the box below. Sign and date any attachments. 1 Primary Applicant (blank if Child-Only) Last Name First Name MI Tobacco use in past 6 Primary Care Physician Name3 1 months?  Yes  No SSN Birthdate (mm/dd/yyyy) M/F U.S. residency for past 6 PCP ID #3 2 months?  Yes  No 2 Spouse (blank if Child-Only) Last Name First Name MI Tobacco use in past 6 Primary Care Physician Name3 1 months?  Yes  No SSN Birthdate (mm/dd/yyyy) M/F U.S. residency for past 6 PCP ID #3 months?2  Yes  No Home Address (if different from Primary Applicant) Relationship to Primary Applicant 3 Dependent Child or Child-Only Last Name

First Name

MI

SSN

Birthdate (mm/dd/yyyy)

M/F

Home Address (if different from Primary Applicant) 4 Dependent Child or Child-Only Last Name

First Name

MI

SSN

Birthdate (mm/dd/yyyy)

M/F

Home Address (if different from Primary Applicant) 5 Dependent Child or Child-Only Last Name

First Name

MI

SSN

Birthdate (mm/dd/yyyy)

M/F

Home Address (if different from Primary Applicant) 6 Dependent Child or Child-Only Last Name

First Name

MI

SSN

Birthdate (mm/dd/yyyy)

M/F

Home Address (if different from Primary Applicant) 7 Dependent Child or Child-Only Last Name

First Name

MI

SSN

Birthdate (mm/dd/yyyy)

M/F

Home Address (if different from Primary Applicant)

Tobacco use in past 6 Primary Care Physician Name3 1 months?  Yes  No U.S. residency for past 6 PCP ID #3 2 months?  Yes  No Relationship to Primary Applicant Tobacco use in past 6 Primary Care Physician Name3 1 months?  Yes  No U.S. residency for past 6 PCP ID #3 months?2  Yes  No Relationship to Primary Applicant Tobacco use in past 6 Primary Care Physician Name3 1 months?  Yes  No U.S. residency for past 6 PCP ID #3 months?2  Yes  No Relationship to Primary Applicant Tobacco use in past 6 Primary Care Physician Name3 months?1  Yes  No U.S. residency for past 6 PCP ID #3 months?2  Yes  No Relationship to Primary Applicant Tobacco use in past 6 Primary Care Physician Name3 months?1  Yes  No U.S. residency for past 6 PCP ID #3 months?2  Yes  No Relationship to Primary Applicant

1 ’Tobacco use’ constitutes use of any tobacco products (excluding the religious or ceremonial use of tobacco) four or more times per week on average within no longer than the past 6

months. 2 ‘U.S. residency” refers to the designated individual living legally in the United States for the past six (6) months. 3 ‘Primary Care Physician (PCP)’ refers to the provider that you would see first for any medical problem. For Health Maintenance Organization (HMO) or Carelink from CoventryOne products, the PCP must be within our provider network. A list of participating providers can be found at the health plan’s website www.chciowa.com. Please note that choice of PCP is not guaranteed; however, you can change your PCP at any time.

Primary Applicant Name: ______________________________ CHCIA-GSA-E-2014

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Agent Name: ____________________________________

Acknowledgements By signing this Application form, I, the Applicant, including any undersigned Spouse and Dependents, agree to the following statements:  I understand that the selling agent (if applicable) has no authority to promise coverage to the applicant or any individual applying for coverage, or to modify Coventry Health Care of Iowa, Inc. (Coventry)’s eligibility criteria, effective date of coverage or terms of coverage.  I understand that the information that I provide on this Application will be used to determine eligibility for health insurance coverage for which I am applying. I attest that my Application responses are complete and accurate to the best of my knowledge.  I understand that if any material information is omitted or misrepresented from any section of the Application, coverage may be refused, terminated, or rescinded, at Coventry’s sole discretion. Coventry may rescind coverage only in cases of fraud or intentional misrepresentation of a material fact. In the event that coverage is rescinded, the policy will be voided back to the original effective date and all premium payments will be refunded. Coventry shall not be financially liable for any health care services rendered prior to the rescission.  I agree to notify Coventry in writing if I or any individual applying for health insurance coverage has any changes to the answers or statements provided on this Application between the date this Application is signed and the effective date or approval date of coverage, whichever is later. My failure to provide Coventry with this updated health information may result in a change of rate, denial or rescission of coverage. DO NOT cancel your existing health coverage until Coventry has notified you in writing that your coverage with Coventry is effective. Please retain a copy of this application for your records. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.

Primary Applicant’s Signature

Date

Spouse’s Signature (if applying for coverage)

Date

Dependent Signature1

Date

Dependent Signature1

Date

The below signatures must be completed if this is a Child-Only Application or if any child applying for health coverage (under the age of 18) has a Custodial Parent2 that is not the Primary Applicant or Spouse of the Primary Applicant. Parent/Legal Guardian Signature

Print Name

Relationship to individual applying for coverage

Date

Custodial Parent Signature2

Print Name

Name of child(ren) to whom this applies

Date

1Dependent 2The

Signature is required for individuals applying for coverage ages 18 and over. Custodial Parent is the person with physical or legal custody of a child under 18 years of age.

FOR AGENT USE ONLY Agent Certification: I am not aware of any other information which may have a bearing on the insurability of anyone to be covered and have not altered any responses recorded on this Application or any supplement to it. I have not advised any individual applying for coverage to withhold any information regarding the answers to the questions and have advised the individuals applying for coverage to review the Application and the answers recorded to confirm completeness and accuracy. I further attest that all my answers recorded in this application are correct, complete, and wholly true to the best of my knowledge and belief. Agent Name Agent ID# Agent E-mail Agency Name Payee (who is paid commissions)  Agent  Agency Agent Signature

Agent / Agency Phone Payee Tax ID#  General Agent

Primary Applicant Name: ______________________________ CHCIA-GSA-E-2014

Name of General Agent

Date

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Agent Name: ____________________________________

Premium Payment Initial Premium Payment Options Choose ONE payment option for initial payment. You must then complete the applicable section regarding your account information.  EFT  Credit card Ongoing Premium Payment Options Choose ONE payment option for ongoing payment. You must then complete the applicable section regarding your account information.  Monthly EFT Payroll Deduction Program (PDP) / Employer List Bill (ELB) This program allows your premium to be deducted directly from your paycheck, on a post-tax basis. Other details apply. To choose this option, you MUST submit a separate Payroll Deduction Authorization Form with your Application.  NEW Payroll Deduction Program (PDP) / Employer List Bill (ELB)

 EXISTING Employer List Bill (ELB)

ELB number: ___________________ ELB name: ___________________________________ EFT (Electronic Funds Transfer) Information Complete this section if you have chosen to pay by EFT. The first month’s premium will automatically be withdrawn from the listed bank account upon issuance. The following monthly premiums will be withdrawn automatically from the bank account listed on the application on the 5th day (or the following business day if a weekend or holiday) in the month for which premium is due. The premium amount due is calculated per day, so if the effective date is anything other than the 1st of the month, the following premium payment will be prorated.  Checking Account Name of Account Holder 9-digit routing number Account Number  Savings Account Name of Bank / Savings Institution Relationship of Account Holder to Primary Applicant  Self  Spouse  Other______________________________ Account Holder Address City State Zip Token

Account Number (Last 4 digits)

Credit Card Information Complete this section if you have chosen to pay by credit card for your initial premium payment(s). The first full month’s premium amount will automatically be charged against the listed credit account upon issuance. Token Account Number (Last 4 digits) Important Note: CoventryOne is not an employer-sponsored group health plan. If your banking information is from a business account, or you are submitting a check drawn from a business account, you must contact us / your agent to complete a CoventryOne Payroll Deduction / Employer List Bill (ELB) Authorization Form. By signing this Premium Payment section, you are agreeing to the following statements:  You understand that it is your responsibility to immediately notify Coventry at 866-364-5663 should your payment or address information change at any time while you continue to hold a CoventryOne policy.  You understand that if premium payment is returned unpaid, a fee will be assessed in the amount of $20.00. Failure to remit the first payment could result in rescission back to your effective date.  You understand that providing this payment information does not guarantee approval for coverage.  Upon issuance of this Application, you authorize Coventry to initiate an immediate automatic withdrawal and / or a billing cycle of applicable premium payments from your provided account or billing information. If your effective date is entered into the system after the third business day of the month, your following automatic withdrawal may include premium amounts for multiple months.  I agree this authorization will remain in effect until I provide written notification terminating this service.

Account / Card Holder Signature:_____________________________________________________Date:___________________________

Primary Applicant Name: ______________________________ CHCIA-GSA-E-2014

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Agent Name: ____________________________________

____________________________________________________________________ Authorization to Use and Disclose Protected Health Information Please read the following carefully before completing your authorization. You may refuse to sign this authorization. Purposes of this Authorization Form By signing this form, I authorize Coventry, or Coventry’s representatives, to request, receive and use Protected Health Information (PHI), including but not limited to, prescribed medication history or other pharmaceutical information, hospital records, physician records, claims or benefit records or lab results for the following purposes: a) to verify tobacco use, b) to coordinate medical care and case management, and/or c) for risk adjustment activities. I authorize Coventry to disclose my PHI for the purposes stated above to other persons or organizations performing services on Coventry’s behalf. I further authorize any licensed physician, medical practitioner, health care provider, hospital, clinic, lab, pharmacy, pharmacy benefit manager or other medical or medically related facility, insurance or reinsuring company, or other organization, institution, or person that has any record or knowledge of my health to disclose such information to Coventry to the extent permitted by law. I understand that Coventry may pay a fee to a third party to collect my health information. The health information released to Coventry may be related to chronic diseases, mental illness, alcohol or substance abuse, Human Immunodeficiency Virus (HIV) infection, or Acquired Immune Deficiency Syndrome (AIDS). Coventry may not condition your treatment, payment, enrollment or eligibility for benefits, on whether or not you sign this authorization. Health information received by Coventry will not be re-disclosed without your authorization unless permitted by law, as described in Coventry’s Notice of Privacy Practices. Information that is re-disclosed may not be protected under federal privacy laws. Term of Authorization I agree this Authorization shall be valid for eighteen (18) months from the signature date below. Right to Revoke I understand that I may revoke this authorization at any time by giving advance written notice to Coventry. My revocation will not have any effect on actions Coventry has already taken before receiving my notice. If this application was completed on a computer, I acknowledge that I have not actually signed this application but instead authorize Coventry to print “Electronic Signature” on this form. I understand that I am entitled to receive a copy of this application upon request, and that a photocopy is as valid as the original. I have read and considered the contents of this form. Primary Applicant’s Signature

Primary Applicant Name: ______________________________ CHCIA-GSA-E-2014

Date

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Agent Name: ____________________________________