Application Submission Guidelines HealthAmerica One

1. Application Submission GuidelinesHealthAmericaOne New business submission and application completion guidelines

2. Forms that are needed with every paper application submission: Required: • APPLICATION • TRUST AGREEMENT Suggested: • MRS FORM (applicants under age 2 or over age 50) • PAYROLL DEDUCTION FORM (required for all applications with business banking account info submitted)

3. APPLICATION • Must pick one desired plan in section A and list requested effective date • Applicant must fully complete sections A, B, C, D and sign and date sections E & F ( Be sure to list complete name, address, and phone info for PCP for all applicants) • Broker must sign section G or H depending on which version of the application is used and put GA name as agency representing broker

4. Trust agreement • Make sure the applicant signs, dates and lists their address on the trust agreement.

5. MRS Authorization FORM • Most often required for applicants under age 2 or over age 49. • 50 and older MUST have seen their PCP or had a physical exam within the last 2 years including whatever tests the doctor deems necessary for that individual’s age. • 55 and older MUST have the PE as well, along with the last 5 years of medical records. • Having this form signed along with every application will significantly reduce turnaround time in obtaining medical records.

6. Payroll Deduction Form • Must be submitted if the check has a business name on the account • If self employed, owner fills out both sections and signs both sections • If employer is submitting premium for employee’s insurance the employer and employee will BOTH need to sign the form • Must be submitted along with application in order to process.

7. JET ISSUE PROSPECTS • UNDERWRITING COMPLETED IN 24-48 BUSINESS HOURS • Height/weight must be within standard range • No prior claims history if previously covered with Coventry/Health America • Must be between age 2 and 49 • All application medical questions must be answered “no” • Case will be sent directly to enrollment to be issued. Can still opt out during the 10 day free look period and receive refund if desired

8. Auto Enrollment Procedure AUTO ENROLLMENT PROCESS • Applications that are approved by UW with all family members applying approved with no rate increase will automatically be sent to enrollment to be issued. • General Agents will still receive email confirmation that the case is being "auto enrolled" with rates, eff date, and plan design noted. NO formal acceptance is required by Health America. • The case will be considered "assumed acceptance" if  all family members applying are covered and approved with no rate increase. • Remember:  the policy will be issued and automatic bank drafts will be processed unless customer opts out during the 10 day free look.

9. How to submit new businessapplications • Submit your new business applications through the following channels: • Submit paper applications. There are three ways to have your applications processed: submit via fax at 1-866-347-2380, email CHCHAPA1Indv@cvty.com or by mail; Attention: Individual Medical Underwriting Dept P.O. Box 67103 Harrisburg, PA 17106-7103 • Submit through eHealth, our new electronic tool • Updates from underwriting by email on all cases, sent to General Agents to be forwarded to writing agents

10. Questions? Nancy Dudek, Account Executive (WPA & OH) nadudek@cvty.com 412-577-5409 / 412-849-9150 / 800-735-2202 ext 5409