Blue Cross And Blue Shield - Account Application Form For Insured Business (Page 3 of 3) in pdf

Part 3

Broker Designation (if applicable)

I hereby authorize

(Broker)

(Agency)

recieve information from Blue Cross and Blue Shield of Massachusetts on

‘s

((Company Name)

behalf and to recieve fee and/or commission compensation on the group health insurance plan(s) established by this account application.

This designation is effective

and will remain in effect until rescinded in writing by me or an authorized

(Date)

representative of

I certify that I have contract signing authority to designate broker payment.

(Company Name)

Name: _____________________________________________Title:________________________________ Date:_____________

Part 4

I Understand That:

(1) Coverage is not effective until approved by Blue Cross and Blue Shield.

(2) Final premium rates are subject to current Blue Cross and Blue Shield underwriting guidelines and FINAL ENROLLMENT.

(3) Requested effective date of coverage may be declined or deferred if the information submitted is incomplete.

(4) Existing coverage should not be canceled until this request is approved.

(5) No broker or consultant may make or modify a contract for Blue Cross and Blue Shield.

(6) All enrolled groups are subject to enrollment eligibility reviews at any time.

(7) All groups must verify their enrollment on an annual basis at renewal.

(8) Groups found to have misrepresented eligibility of subscribers(s) are subject to immediate cancellation, with no conversion privileges,

and are liable for all benefits paid for inappropriately enrolled subscribers.

(9)The Premium Account Agreement will be considered accepted and binding when the Account first makes a payment to

Blue Cross and Blue Shield.

(10) Premium payment is due on or before the date listed on each invoice. Amounts past due are subject to an interest charge

of up to 1.5% per month, as described in your Premium Account Agreement.

I certify that the information in this application is true and complete.

Non-Discrimination under Massachusetts Law

By signing below, I confirm that each Blue Cross and Blue Shield product for Massachusetts residents is

being offered by

(company name) to all full-time employees in Massachusetts and,

except as permitted

(company name) does not contribute a smaller percentage

of the premium for lower paid full-time employees than higher paid full-time employees who live in Massachusetts and enroll in

the same product. (This non-discrimination provision does not apply to employees covered by collective bargaining agreements).

Signed By (Authorized Employer Representative)

Title

Date

Company Name

Sales Executive

Date

Regional Office

Territory No.

Telephone

Blue Cross And Blue Shield - Account Application Form For Insured Business Page 3

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