Common use of Enrollment Requirements Clause in Contracts

Enrollment Requirements. Group may offer the coverage described in Part C of this Agreement to eligible individuals as described in Section 4. To continue coverage, the number of eligible individuals enrolled in a Blue Family Benefit Program (Blue Care Network or Traditional, PPO, or any other program that BCN may establish) must at all times equal or exceed BCN enrollment, participation and underwriting requirements. The Group agrees to provide BCN or its designee with all information required to conduct an annual underwriting review and a payroll audit. Continued on Page 3 Group Name: Signature of Group Executive: Date: Signature of BCN Rep: Mail Code: Date: Signature of Agent: Date: Signature of Underwriter: _______________________________________________________________________ Date: __________ _ Group ID Sub Group ID_ Class ID Group Enrollment and Coverage Agreement Group Letter of Agreement - Part A New Group con't Group Exec Initials Federal Tax ID Number -

Enrollment Requirements. Group may offer the coverage described in Part C of this Agreement to eligible individuals as described in Section 4. To continue coverage, the number of eligible individuals enrolled in a Blue Family Benefit Program (Blue Care Network or Traditional, PPO, or any other program that BCN may establish) must at all times equal or exceed BCN enrollment, participation and underwriting requirements. The Group agrees to provide BCN or its designee with all information required to conduct an annual underwriting review and a payroll audit. Continued on Page 3 Group Name: Signature of Group Executive: Date: Signature of BCN Rep: Mail Code: Date: Signature of Agent: Date: Signature of Underwriter: _______________________________________________________________________ Date: __________ _ Group ID Sub Group ID_ Class ID Small Group Enrollment and Coverage Agreement Group Letter of Agreement - Part A New Group con't Group Exec Initials Federal Tax ID Number -

Enrollment Requirements. Group may offer the coverage described in Part C of this Agreement to eligible individuals as described in Section 4. To continue coverage, the number of eligible individuals enrolled in a Blue Family Benefit Program (Blue Care Network or Traditional, PPO, or any other program that BCN may establish) must at all times equal or exceed BCN enrollment, participation and underwriting requirements. The Group agrees to provide BCN or its designee with all information required to conduct an annual underwriting review and a payroll audit. Continued on Page 3 Group Name: Signature of Group Executive: Date: Signature of BCN Rep: Mail Code: Date: Signature of Agent: Date: Date: Date: Signature of Underwriter: _______________________________________________________________________ Date: __________ _ Group ID Sub Group ID_ Class ID Small Group Enrollment and Coverage Agreement Group Letter of Agreement - Part A New Group con't Group Exec Initials Federal Tax ID Number -

Enrollment Requirements. Group may offer the coverage described in Part C of this Agreement to eligible individuals as described in Section 4. To continue coverage, the number of eligible individuals enrolled in a Blue Family Benefit Program (Blue Care Network or Traditional, PPO, or any other program that BCN may establish) must at all times equal or exceed BCN enrollment, participation and underwriting requirements. The Group agrees to provide BCN or its designee with all information required to conduct an annual underwriting review and a payroll audit. Continued on Page 3 Group Name: Signature of Group Executive: Date: Signature of BCN Rep: Mail Code: Date: Signature of Agent: Date: Date: Date: Signature of Underwriter: _______________________________________________________________________ Date: __________ _ Group ID Sub Group ID_ Class ID Large Group Enrollment and Coverage Agreement Group Letter of Agreement - Part A New Group con't Group Exec Initials Federal Tax ID Number -

Enrollment Requirements. Group may offer the coverage described in Part C of this Agreement to eligible individuals as described in Section 4. To continue coverage, the number of eligible individuals enrolled in a Blue Family Benefit Program (Blue Care Network or Traditional, PPO, or any other program that BCN may establish) must at all times equal or exceed BCN enrollment, participation and underwriting requirements. The Group agrees to provide BCN or its designee with all information required to conduct an annual underwriting review and a payroll audit. Continued on Page 3 Group Name: Signature of Group Executive: Date: Signature of BCN Rep: Mail Code: Date: Signature of Agent: Date: Date: Date: Signature of Underwriter: _______________________________________________________________________ Date: __________ _ Group ID Sub Group ID_ Class ID Group Enrollment and Coverage Agreement Group Letter of Agreement - Part A New Group con't Group Exec Initials Federal Tax ID Number -