Common use of Types of Coverage Clause in Contracts

Types of Coverage. The Contractholder who completes an application for coverage may elect coverage just for him/herself and may add one or more eligible Dependents for coverage. The possible types of coverage listed below: • Single Coverage - coverage under this Contract for only one person. • Family Coverage - coverage under this Contract for You, Your Spouse and Your Dependent child(ren). • Adult and Child(ren) Coverage - coverage under this Contract for You and Your Dependent child(ren) [or coverage for multiple children residing within the same residence who share a common legal guardian, or for when there exists a valid support order requiring health benefit coverage whether or not there is an adult who will be provided coverage]. • [Single and Spouse] [Two Adults] Coverage - coverage under this Contract for You and Your Spouse. Who is Eligible The Contractholder -You, if You are an Eligible Person, [who lives in the designated Service Area in the State of New Jersey]. Spouse - Your Spouse [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person except: a Spouse need not be a Resident; [but must be a U.S. Citizen, National or lawfully present in the United States].Child - Your child [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person and who qualifies as a Dependent, as defined in this Contract, except: a child need not be a Resident;[but must be a U.S. Citizen, National or lawfully present in the United States]. You may have an unmarried child with a mental or physical handicap, or developmental disability, who is incapable of earning a living. Subject to all of the terms of this section and the Contract, such a child may stay eligible for Dependent health benefits past this Contract's age limit for eligible Dependents. The child will stay eligible as long as the child is and remains unmarried and incapable of earning a living, if: a) the child's condition started before he or she reached this Contract's age limit; b) the child became covered under this Contract or any other policy or contract before the child reached the age limit and stayed continuously covered or covered after reaching such limit; and c) the child depends on You for most of his or her support and maintenance. But, for the child to stay eligible, You must send Us written proof that the child is incapacitated or developmentally disabled and depends on You for most of his or her support and maintenance. You have 31 days from the date the child reaches the age limit to do this. We can ask for periodic proof that the child's condition continues. But, after two years, We cannot ask for proof more than once a year. The child's coverage ends when Your coverage ends. In order to obtain and continue health care coverage with Us, the Member, who is not covered as either a Dependent Spouse or as a Dependent child, must be a Resident [and a U.S. Citizen, National, or lawfully present in the United States]. We reserve the right to require proof that such Member is a Resident[and a U.S. Citizen, National, or lawfully present in the United States]. Adding dependents to this contract Spouse - You may apply to add Your Spouse by notifying Us in writing. If Your application is made and submitted to Us within 60 days of Your marriage or documentation of domestic partnership or civil union, the Spouse will be covered. as of the first [or fifteenth] of the month following the date We receive the application. In case of a court order, coverage of a spouse as required by a court order will be effective as of the date specified in the court order. If You do not submit an application within 60 days of Your Spouse becoming eligible, You may apply to add coverage for Your Spouse during an Annual Open Enrollment Period or during an applicable Special Enrollment Period. Newborn Children - We will cover Your newborn child for 31 days from the date of birth without additional premium. Coverage may be continued beyond such 31-day period as stated below: You must: a) give written notice to enroll the newborn child; and b) pay any additional premium required for Dependent child coverage within 60 days after the date of birth for coverage to continue beyond the initial 31 days. If the notice is not given and the premium is not paid within such 60-day period, the newborn child’s coverage will end at the end of such 31-day period. You may apply for coverage for the Child during an Annual Open Enrollment Period or during any applicable Special Enrollment Period.

Types of Coverage. The Contractholder who completes an application for coverage may elect coverage just for him/herself and may add one or more eligible Dependents for coverage. The possible types of coverage listed below: • Single Coverage - coverage under this Contract for only one person. • Family Coverage - coverage under this Contract for You, Your Spouse and Your Dependent child(ren). • Adult and Child(ren) Coverage - coverage under this Contract for You and Your Dependent child(ren) [or coverage for multiple children residing within the same residence who share a common legal guardian, or for when there exists a valid support order requiring health benefit coverage whether or not there is an adult who will be provided coverage]. • [Single and Spouse] [Two Adults] Coverage - coverage under this Contract for You and Your Spouse. Who is Eligible The Contractholder -You, if You are an Eligible Person, [who lives in the designated Service Area in the State of New Jersey]. Spouse - Your Spouse [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person except: a Spouse need not be a Resident; [but must be a U.S. Citizen, National or lawfully present in the United States].Child - Your child [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person and who qualifies as a Dependent, as defined in this Contract, except: a child need not be a Resident;[but must be a U.S. Citizen, National or lawfully present in the United States]. You may have an unmarried child with a mental or physical handicap, or developmental disability, who is incapable of earning a living. Subject to all of the terms of this section and the Contract, such a child may stay eligible for Dependent health benefits past this Contract's age limit for eligible Dependents. The child will stay eligible as long as the child is and remains unmarried and incapable of earning a living, if: a) the child's condition started before he or she reached this Contract's age limit; b) the child became covered under this Contract or any other policy or contract before the child reached the age limit and stayed continuously covered or covered after reaching such limit; and c) the child depends on You for most of his or her support and maintenance. But, for the child to stay eligible, You must send Us written proof that the child is incapacitated or developmentally disabled and depends on You for most of his or her support and maintenance. You have 31 days from the date the child reaches the age limit to do this. We can ask for periodic proof that the child's condition continues. But, after two years, We cannot ask for proof more than once a year. The child's coverage ends when Your coverage ends. In order to obtain and continue health care coverage with Us, the Member, who is not covered as either a Dependent Spouse or as a Dependent child, must be a Resident [and a U.S. Citizen, National, or lawfully present in the United States]. We reserve the right to require proof that such Member is a Resident[and a U.S. Citizen, National, or lawfully present in the United States]. Adding dependents to this contract Spouse - You may apply to add Your Spouse by notifying Us in writing. If Your application is made and submitted to Us within 60 days of Your marriage or documentation of domestic partnership or civil union, the Spouse will be covered. as of the first [or fifteenth] of the month following the date We receive the application. In case of a court order, coverage of a spouse as required by a court order will be effective as of the date specified in the court order. If You do not submit an application within 60 days of Your Spouse becoming eligible, You may apply to add coverage for Your Spouse during an Annual Open Enrollment Period or during an applicable Special Enrollment Period. Newborn Children - We will cover Your newborn child for 31 days from the date of birth without additional premium. Coverage may be continued beyond such 31-day period as stated below: You must: a) give written notice to enroll the newborn child; and b) pay any additional premium required for Dependent child coverage within 60 days after the date of birth for coverage to continue beyond the initial 31 days. If the notice is not given and the premium is not paid within such 60-day period, the newborn child’s coverage will end at the end of such 31-day period. You may apply for coverage for the Child during an Annual Open Enrollment Period or during any applicable Special Enrollment Period.

Types of Coverage. The Contractholder who completes an application for coverage may elect coverage just for him/herself and may add one or more eligible Dependents for coverage. The possible types of coverage listed below: • Single Coverage - coverage under this Contract for only one person. • Family Coverage - coverage under this Contract for You, Your Spouse and Your Dependent child(ren). • Adult and Child(ren) Coverage - coverage under this Contract for You and all Your Dependent child(ren) [or coverage for multiple children residing within the same residence who share a common legal guardian, or for when there exists a valid support order requiring health benefit coverage whether or not there is an adult who will be provided coverage]. • [Single and Spouse] [Two Adults] Spouse Coverage - coverage under this Contract for You and Your Spouse. Who is Eligible The Contractholder -You, if You are an Eligible Person, [who lives in the designated Service Area in the State of New Jersey]. Spouse - Your Spouse [who lives, resides or works lives in the designated Service Area in the State of New Jersey.], who is an Eligible Person except: a Spouse need not be a Resident; [but must be a U.S. Citizen, National or lawfully present in the United States].Child . Child - Your child [who lives, resides or works lives in the designated Service Area in the State of New Jersey.], who is an Eligible Person and who qualifies as a Dependent, as defined in this Contract, except: a child Child need not be a Resident;[but must be a U.S. Citizen, National or lawfully present in the United States]Resident. You may have an unmarried child with a mental or physical handicap, or developmental disability, who is incapable of earning a living. Subject to all of the terms of this section and the Contract, such a child may stay eligible for Dependent health benefits past this Contract's age limit for eligible Dependents. The child will stay eligible as long as the child is and remains unmarried and incapable of earning a living, if: a) the child's condition started before he or she reached this Contract's age limit; b) the child became covered under this Contract or any other policy or contract before the child reached the age limit and stayed continuously covered or covered after reaching such limit; and c) the child depends on You for most of his or her support and maintenance. But, for the child to stay eligible, You must send Us written proof that the child is incapacitated or developmentally disabled and depends on You for most of his or her support and maintenance. You have 31 days from the date the child reaches the age limit to do this. We can ask for periodic proof that the child's condition continues. But, after two years, We cannot ask for proof more than once a year. The child's coverage ends when Your coverage ends. In order to obtain and continue health care coverage with Us, the Member, who is not covered as either a Dependent Spouse or as a Dependent childChild, must be a Resident [and a U.S. Citizen, National, or lawfully present in the United States]Resident. We reserve the right to require proof that such Member is a Resident[and a U.S. Citizen, National, or lawfully present in the United States]Resident. Adding dependents to this contract contract: Spouse - You may apply to add Your Spouse by notifying Us in writing. .. If Your application is made and submitted to Us within 60 days of Your marriage or documentation of domestic partnership or civil union, the Spouse will be covered. covered as of the first [or fifteenth] fifteenth of the month following the date We receive the application. In case of a court order, coverage of a spouse Spouse as required by a court order will be effective as of the date specified in the court order. If You do not submit an application within 60 days of Your Spouse becoming eligible, You may apply to add coverage for Your Spouse during an Annual Open Enrollment Period or during an applicable Special Enrollment Period. Newborn Children - We will cover Your newborn child for 31 days from the date of birth without additional premium. Coverage may be continued beyond such 31-day period as stated below: You must: a) give written notice to enroll the newborn child; and b) pay any additional premium required for Dependent child coverage within 60 days after the date of birth for coverage to continue beyond the initial 31 days. If the notice is not given and the premium is not paid within such 60-day period, the newborn child’s coverage will end at the end of such 31-day period. You may apply for coverage for the Child during an Annual Open Enrollment Period or during any applicable Special Enrollment Period.

Types of Coverage. The Contractholder who completes an application for coverage may elect coverage just for him/herself and may add one or more eligible Dependents for coverage. The possible types of coverage listed below: • Single Coverage - coverage under this Contract for only one person. • Family Coverage - coverage under this Contract for You, Your Spouse and Your Dependent child(ren). • Adult and Child(ren) Coverage - coverage under this Contract for You and Your Dependent child(ren) [or coverage for multiple children residing within the same residence who share a common legal guardian, or for when there exists a valid support order requiring health benefit coverage whether or not there is an adult who will be provided coverage]. • [Single and Spouse] [Two Adults] Coverage - coverage under this Contract for You and Your Spouse. Who is Eligible The Contractholder -You, if You are an Eligible Person, [who lives in the designated Service Area in the State of New Jersey]. Spouse - Your Spouse [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person except: a Spouse need not be a Resident; [but must be a U.S. Citizen, National or lawfully present in the United States].Child - Your child [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person and who qualifies as a Dependent, as defined in this Contract, except: a child need not be a Resident;[but must be a U.S. Citizen, National or lawfully present in the United States]. You may have an unmarried child with a mental or physical handicap, or developmental disability, who is incapable of earning a living. Subject to all of the terms of this section and the Contract, such a child may stay eligible for Dependent health benefits past this Contract's age limit for eligible Dependents. The child will stay eligible as long as the child is and remains unmarried and incapable of earning a living, if: a) the child's condition started before he or she reached this Contract's age limit; b) the child became covered under this Contract or any other policy or contract before the child reached the age limit and stayed continuously covered or covered after reaching such limit; and c) the child depends on You for most of his or her support and maintenance. But, for the child to stay eligible, You must send Us written proof that the child is incapacitated or developmentally disabled and depends on You for most of his or her support and maintenance. You have 31 days from the date the child reaches the age limit to do this. We can ask for periodic proof that the child's condition continues. But, after two years, We cannot ask for proof more than once a year. The child's coverage ends when Your coverage ends. In order to obtain and continue health care coverage with Us, the Member, who is not covered as either a Dependent Spouse or as a Dependent child, must be a Resident [and a U.S. Citizen, National, or lawfully present in the United States]. We reserve the right to require proof that such Member is a Resident[and a U.S. Citizen, National, or lawfully present in the United States]. Adding dependents to this contract Spouse - You may apply to add Your Spouse by notifying Us in writing. If Your application is made and submitted to Us within 60 days of Your marriage or documentation of domestic partnership or civil union, the Spouse will be covered. as of the first [or fifteenth] of the month following the date We receive the application. In case of a court order, coverage of a spouse as required by a court order will be effective as of the date specified in the court order. If You do not submit an application within 60 days of Your Spouse becoming eligible, You may apply to add coverage for Your Spouse during an Annual Open Enrollment Period or during an applicable Special Enrollment Period. Newborn Children - We will cover Your newborn child for 31 days from the date of birth without additional premium. Coverage may be continued beyond such 31-day period as stated below: You must: a) give written notice to enroll the newborn child; and b) pay any additional premium required for Dependent child coverage within 60 days after the date of birth for coverage to continue beyond the initial 31 days. If the notice is not given and the premium is not paid within such 60-day period, the newborn child’s coverage will end at the end of such 31-day period. You may apply for coverage for the Child during an Annual Open Enrollment Period or during any applicable Special Enrollment Period.

Types of Coverage. The Contractholder who completes an application for coverage may elect coverage just for him/herself and may add one or more eligible Dependents for coverage. The possible of the types of coverage listed below: •  Single Coverage - coverage under this Contract for only one person. •  Family Coverage - coverage under this Contract for You, Your Spouse You and Your Dependent child(renDependent(s). •  Adult and Child(ren) Coverage - coverage under this Contract for You and all Your Dependent child(ren) [Child Dependents or coverage for multiple children residing within the same residence who share a common legal guardian, or for when there exists a valid support order requiring health benefit coverage whether or not there is an adult who will be provided coverage]. • [ Single and Spouse] [Two Adults] Spouse Coverage - coverage under this Contract for You and Your Spouse. Who is Eligible The Contractholder -You, if You are an Eligible Person, [who lives lives, resides or works in the designated Service Area in the State of New Jersey]] except as provided below. Spouse - Your Spouse [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person except: a Spouse need not be a Resident; [but must be a U.S. Citizen, National or lawfully present in the United States].Child and except as provided below. Child - Your child [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person and who qualifies as a Dependent, as defined in this Contract, except: a child Child need not be a Resident;[but must be a U.S. Citizen, National or lawfully present in the United States]Resident; and except as provided below. You may have an unmarried child with a mental or physical handicap, or developmental disability, who is incapable of earning a living. Subject to all of the terms of this section and the Contract, such a child may stay eligible for Dependent health benefits past this Contract's age limit for eligible Dependents. The child will stay eligible as long as the child is and remains unmarried and incapable of earning a living, if: a) the child's condition started before he or she reached this Contract's age limit; b) the child became covered under this Contract or any other policy or contract before the child reached the age limit and stayed continuously covered or covered after reaching such limit; and c) the child depends on You for most of his or her support and maintenance. But, for the child to stay eligible, You must send Us written proof that the child is incapacitated or developmentally disabled and depends on You for most of his or her support and maintenance. You have 31 days from the date the child reaches the age limit to do this. We can ask for periodic proof that the child's condition continues. But, after two years, We cannot ask for proof more than once a year. The child's coverage ends when Your coverage ends. In order to obtain and continue health care coverage with Us, the Member, who is not covered as either a Dependent Spouse or as a Dependent childChild, must be a Resident [and a U.S. Citizen, National, or lawfully present in the United States]Resident. We reserve the right to require proof that such Member is a Resident[and Resident. Eligibility if you have or are eligible for other coverage Eligibility if you are covered under another individual health benefits plan - You and/or Your Dependents are eligible for coverage under this Contract if this Contract replaces another Individual Health Benefits Plan under which You and/or Your Dependents are covered. You may request termination of the replaced Individual Health Benefits Plan pursuant to the termination provisions of that Plan. We may require proof that the other coverage has been terminated. Eligibility if you are eligible for coverage under a U.S. Citizen, National, group health benefits plan - You and/or Dependents may be eligible for coverage under this Contract only during the open enrollment period which occurs each year during the month of November for an effective date of January 1 of the following year. Consult Us or lawfully present in the United States]Your agent for more information. Adding dependents to this contract Spouse - You may apply to add Your Spouse by notifying Us in writingwriting at any time. You must submit an application to Us to change Your type of coverage. If Your application is made and submitted to Us within 60 31 days of Your marriage or documentation of domestic partnership or civil union, the Spouse will be covered. as covered from the date of the first [or fifteenth] of the month following the date We receive the application. In case of a court order, coverage of a spouse as required by a court order will be effective as of the date specified in the court orderSpouse’s eligibility. If You We do not submit an application receive Your written notice within 60 31 days of Your Spouse becoming eligible, You may apply to add coverage for Your Spouse during an Annual Open Enrollment Period or during an applicable Special Enrollment Periodwill not become effective immediately. Rather, such coverage will become effective on the first day of the month after the date Your application is received. Newborn Children - We will cover Your newborn child for 31 days from the date of birth without additional premium. Coverage may be continued beyond such 31-day period as stated below: If You are already covered for Dependent child coverage on the date the child is born, coverage automatically continues beyond the initial 31 days, provided the premium required for Dependent child coverage continues to be paid. You must notify Us of the birth of the newborn child as soon as possible in order that We may properly provide coverage under this Contract. If You are not covered for Dependent child coverage on the date the child is born, You must: a) give written notice to enroll the newborn child; and b) pay any additional the premium required for Dependent child coverage within 60 31 days after the date of birth for coverage to continue beyond the initial 31 days. If the notice is not given and the premium is not paid within such 6031-day period, the newborn child’s coverage will end at the end of such 31-day period. If the notice is given and the premium paid after that 31-day period, such coverage will become effective on the first day of the month after the date Your application is received. Child Dependent - If You may apply for have Single or Two Adult Coverage and want to add a child Dependent, other than a Newborn Child, You must change to Family Coverage or Adult and Child(ren) Coverage. To change coverage, You must submit an application. If Your application is made and submitted to Us within 31 days of the child's becoming a Dependent, the Child will be covered from the date of his or her eligibility. Even if You have Family Coverage or Adult and Child(ren) Coverage, however, You must give Us written notice that You wish to add a child. If Your written notice to add a child is made and submitted to Us within 31 days of the Child's becoming a Dependent, the Child will be covered from the date of eligibility. If We do not receive Your written notice within 31 days of Your Dependent's becoming eligible, coverage for that Dependent will not become effective immediately. Rather, such coverage will become effective on the Child during an Annual Open Enrollment Period or during any applicable Special Enrollment Periodfirst day of the month after the date Your application is received.

Types of Coverage. The Contractholder who completes an application for coverage may elect coverage just for him/herself and may add one or more eligible Dependents for coverage. The possible of the types of coverage listed below: • Single Coverage - coverage under this Contract for only one person. • Family Coverage - coverage under this Contract for You, Your Spouse You and Your Dependent child(renDependent(s). • Adult and Child(ren) Coverage - coverage under this Contract for You and all Your Dependent child(ren) [Child Dependents or coverage for multiple children residing within the same residence who share a common legal guardian, or for when there exists a valid support order requiring health benefit coverage whether or not there is an adult who will be provided coverage]. • [Single and Spouse] [Two Adults] Spouse Coverage - coverage under this Contract for You and Your Spouse. Who is Eligible The Contractholder -You, if You are an Eligible Person, [who lives lives, resides or works in the designated Service Area in the State of New Jersey]] except as provided below. Spouse - Your Spouse [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person except: a Spouse need not be a Resident; [but must be a U.S. Citizen, National or lawfully present in the United States].Child and except as provided below. Child - Your child [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person and who qualifies as a Dependent, as defined in this Contract, except: a child Child need not be a Resident;[but must be a U.S. Citizen, National or lawfully present in the United States]Resident; and except as provided below. You may have an unmarried child with a mental or physical handicap, or developmental disability, who is incapable of earning a living. Subject to all of the terms of this section and the Contract, such a child may stay eligible for Dependent health benefits past this Contract's age limit for eligible Dependents. The child will stay eligible as long as the child is and remains unmarried and incapable of earning a living, if: a) the child's condition started before he or she reached this Contract's age limit; b) the child became covered under this Contract or any other policy or contract before the child reached the age limit and stayed continuously covered or covered after reaching such limit; and c) the child depends on You for most of his or her support and maintenance. But, for the child to stay eligible, You must send Us written proof that the child is incapacitated or developmentally disabled and depends on You for most of his or her support and maintenance. You have 31 days from the date the child reaches the age limit to do this. We can ask for periodic proof that the child's condition continues. But, after two years, We cannot ask for proof more than once a year. The child's coverage ends when Your coverage ends. In order to obtain and continue health care coverage with Us, the Member, who is not covered as either a Dependent Spouse or as a Dependent childChild, must be a Resident [and a U.S. Citizen, National, or lawfully present in the United States]Resident. We reserve the right to require proof that such Member is a Resident[and Resident. Eligibility if you have or are eligible for other coverage Eligibility if you are covered under another individual health benefits plan - You and/or Your Dependents are eligible for coverage under this Contract if this Contract replaces another Individual Health Benefits Plan under which You and/or Your Dependents are covered. You may request termination of the replaced Individual Health Benefits Plan pursuant to the termination provisions of that Plan. We may require proof that the other coverage has been terminated. Eligibility if you are eligible for coverage under a U.S. Citizen, National, group health benefits plan - You and/or Dependents may be eligible for coverage under this Contract only during the open enrollment period which occurs each year during the month of November for an effective date of January 1 of the following year. Consult Us or lawfully present in the United States]Your agent for more information. Adding dependents to this contract Spouse - You may apply to add Your Spouse by notifying Us in writingwriting at any time. You must submit an application to Us to change Your type of coverage. If Your application is made and submitted to Us within 60 31 days of Your marriage or documentation of domestic partnership or civil union, the Spouse will be covered. as covered from the date of the first [or fifteenth] of the month following the date We receive the application. In case of a court order, coverage of a spouse as required by a court order will be effective as of the date specified in the court orderSpouse’s eligibility. If You We do not submit an application receive Your written notice within 60 31 days of Your Spouse becoming eligible, You may apply to add coverage for Your Spouse during an Annual Open Enrollment Period or during an applicable Special Enrollment Periodwill not become effective immediately. Rather, such coverage will become effective on the first day of the month after the date Your application is received. Newborn Children - We will cover Your newborn child for 31 days from the date of birth without additional premium. Coverage may be continued beyond such 31-day period as stated below: If You are already covered for Dependent child coverage on the date the child is born, coverage automatically continues beyond the initial 31 days, provided the premium required for Dependent child coverage continues to be paid. You must notify Us of the birth of the newborn child as soon as possible in order that We may properly provide coverage under this Contract. If You are not covered for Dependent child coverage on the date the child is born, You must: a) give written notice to enroll the newborn child; and b) pay any additional the premium required for Dependent child coverage within 60 31 days after the date of birth for coverage to continue beyond the initial 31 days. If the notice is not given and the premium is not paid within such 6031-day period, the newborn child’s coverage will end at the end of such 31-day period. If the notice is given and the premium paid after that 31-day period, such coverage will become effective on the first day of the month after the date Your application is received. Child Dependent - If You may apply for have Single or Two Adult Coverage and want to add a child Dependent, other than a Newborn Child, You must change to Family Coverage or Adult and Child(ren) Coverage. To change coverage, You must submit an application. If Your application is made and submitted to Us within 31 days of the child's becoming a Dependent, the Child will be covered from the date of his or her eligibility. Even if You have Family Coverage or Adult and Child(ren) Coverage, however, You must give Us written notice that You wish to add a child. If Your written notice to add a child is made and submitted to Us within 31 days of the Child's becoming a Dependent, the Child will be covered from the date of eligibility. If We do not receive Your written notice within 31 days of Your Dependent's becoming eligible, coverage for that Dependent will not become effective immediately. Rather, such coverage will become effective on the Child during an Annual Open Enrollment Period or during any applicable Special Enrollment Periodfirst day of the month after the date Your application is received.

Types of Coverage. The Contractholder who completes an application for coverage may elect coverage just for him/herself and may add one or more eligible Dependents for coverage. The possible of the types of coverage listed below: • Single Coverage - coverage under this Contract for only one person. • Family Coverage - coverage under this Contract for You, Your Spouse You and Your Dependent child(renDependent(s). • Adult and Child(ren) Coverage - coverage under this Contract for You and all Your Dependent child(ren) [Child Dependents or coverage for multiple children residing within the same residence who share a common legal guardian, or for when there exists a valid support order requiring health benefit coverage whether or not there is an adult who will be provided coverage]. • [Single and Spouse] [Two Adults] Spouse Coverage - coverage under this Contract for You and Your Spouse. Who is Eligible The Contractholder -You, if You are an Eligible Person, [who lives lives, resides or works in the designated Service Area in the State of New Jersey]] except as provided below. Spouse - Your Spouse [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person except: a Spouse need not be a Resident; [but must be a U.S. Citizen, National or lawfully present in the United States].Child and except as provided below. Child - Your child [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person and who qualifies as a Dependent, as defined in this Contract, except: a child Child need not be a Resident;[but must be a U.S. Citizen, National or lawfully present in the United States]Resident; and except as provided below. You may have an unmarried child with a mental or physical handicap, or developmental disability, who is incapable of earning a living. Subject to all of the terms of this section and the Contract, such a child may stay eligible for Dependent health benefits past this Contract's age limit for eligible Dependents. The child will stay eligible as long as the child is and remains unmarried and incapable of earning a living, if: a) the child's condition started before he or she reached this Contract's age limit; b) the child became covered under this Contract or any other policy or contract before the child reached the age limit and stayed continuously covered or covered after reaching such limit; and c) the child depends on You for most of his or her support and maintenance. But, for the child to stay eligible, You must send Us written proof that the child is incapacitated or developmentally disabled and depends on You for most of his or her support and maintenance. You have 31 days from the date the child reaches the age limit to do this. We can ask for periodic proof that the child's condition continues. But, after two years, We cannot ask for proof more than once a year. The child's coverage ends when Your coverage ends. In order to obtain and continue health care coverage with Us, the Member, who is not covered as either a Dependent Spouse or as a Dependent childChild, must be a Resident [and a U.S. Citizen, National, or lawfully present in the United States]Resident. We reserve the right to require proof that such Member is a Resident[and Resident. Eligibility if you have or are eligible for other coverage Eligibility if you are covered under another individual health benefits plan - You and/or Your Dependents are eligible for coverage under this Contract if this Contract replaces another Individual Health Benefits Plan under which You and/or Your Dependents are covered. You may request termination of the replaced Individual Health Benefits Plan pursuant to the termination provisions of that Plan. We may require proof that the other coverage has been terminated. Eligibility if you are eligible for coverage under a U.S. Citizen, National, group health benefits plan - You and/or Dependents may be eligible for coverage under this Contract only during the open enrollment period which occurs each year during the month of November for an effective date of January 1 of the following year. Consult Us or lawfully present in the United States]Your agent for more information. Adding dependents to this contract Spouse - You may apply to add Your Spouse by notifying Us in writingwriting at any time. You must submit an application to Us to change Your type of coverage. If Your application is made and submitted to Us within 60 31 days of Your marriage or documentation of domestic partnership or civil union, the Spouse will be covered. as covered from the date of the first [or fifteenth] of the month following the date We receive the application. In case of a court order, coverage of a spouse as required by a court order will be effective as of the date specified in the court orderSpouse’s eligibility. If You We do not submit an application receive Your written notice within 60 31 days of Your Spouse becoming eligible, You may apply to add coverage for Your Spouse during an Annual Open Enrollment Period or during an applicable Special Enrollment Periodwill not become effective immediately. Rather, such coverage will become effective on the first day of the month after the date Your application is received. Newborn Children - We will cover Your newborn child for 31 days from the date of birth without additional premium. Coverage may be continued beyond such 31-day period as stated below: If You are already covered for Dependent child coverage on the date the child is born, coverage automatically continues beyond the initial 31 days, provided the premium required for Dependent child coverage continues to be paid. You must notify Us of the birth of the newborn child as soon as possible in order that We may properly provide coverage under this Contract. If You are not covered for Dependent child coverage on the date the child is born, You must: a) give written notice to enroll the newborn child; and b) pay any additional the premium required for Dependent child coverage within 60 31 days after the date of birth for coverage to continue beyond the initial 31 days. If the notice is not given and the premium is not paid within such 6031-day period, the newborn child’s coverage will end at the end of such 31-day period. If the notice is given and the premium paid after that 31-day period, such coverage will become effective on the first day of the month after the date Your application is received. Child Dependent - If You may apply for have Single or Two Adult Coverage and want to add a child Dependent, other than a Newborn Child, You must change to Family Coverage or Adult and Child(ren) Coverage. To change coverage, You must submit an application. If Your application is made and submitted to Us within 31 days of the child's becoming a Dependent, the Child will be covered from the date of his or her eligibility. Even if You have Family Coverage or Adult and Child(ren) Coverage, however, You must give Us written notice that You wish to add a child. If Your written notice to add a child is made and submitted to Us within 31 days of the Child's becoming a Dependent, the Child will be covered from the date of eligibility. If We do not receive Your written notice within 31 days of Your Dependent's becoming eligible, coverage for that Dependent will not become effective immediately. Rather, such coverage will become effective on the Child during an Annual Open Enrollment Period or during any applicable Special Enrollment Periodfirst day of the month after the date Your application is received.

Types of Coverage. The Contractholder who completes an application for coverage may elect coverage just for him/herself and may add one or more eligible Dependents for coverage. The possible of the types of coverage listed below: • Single Coverage - coverage under this Contract for only one person. • Family Coverage - coverage under this Contract for You, Your Spouse You and Your Dependent child(renDependent(s). • Adult and Child(ren) Coverage - coverage under this Contract for You and all Your Dependent child(ren) [Child Dependents or coverage for multiple children residing within the same residence who share a common legal guardian, or for when there exists a valid support order requiring health benefit coverage whether or not there is an adult who will be provided coverage]. • [Single and Spouse] [Two Adults] Spouse Coverage - coverage under this Contract for You and Your Spouse. Who is Eligible The Contractholder -You, if You are an Eligible Person, [who lives lives, resides or works in the designated Service Area in the State of New Jersey]] except as provided below. Spouse - Your Spouse [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person except: a Spouse need not be a Resident; [but must be a U.S. Citizen, National or lawfully present in the United States].Child and except as provided below. Child - Your child [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person and who qualifies as a Dependent, as defined in this Contract, except: a child Child need not be a Resident;[but must be a U.S. Citizen, National or lawfully present in the United States]Resident; and except as provided below. You may have an unmarried child with a mental or physical handicap, or developmental disability, who is incapable of earning a living. Subject to all of the terms of this section and the Contract, such a child may stay eligible for Dependent health benefits past this Contract's age limit for eligible Dependents. The child will stay eligible as long as the child is and remains stays unmarried and incapable of earning a living, if: a) the child's condition started before he or she reached this Contract's age limit; b) the child became covered under this Contract or any other policy or contract before the child reached the age limit and stayed continuously covered or covered after reaching such limit; and c) the child depends on You for most of his or her support and maintenance. But, for the child to stay eligible, You must send Us written proof that the child is incapacitated or developmentally disabled and depends on You for most of his or her support and maintenance. You have 31 days from the date the child reaches the age limit to do this. We can ask for periodic proof that the child's condition continues. But, after two years, We cannot ask for proof more than once a year. The child's coverage ends when Your coverage ends. In order to obtain and continue health care coverage with Us, the Member, who is not covered as either a Dependent Spouse or as a Dependent childChild, must be a Resident [and a U.S. Citizen, National, or lawfully present in the United States]Resident. We reserve the right to require proof that such Member is a Resident[and Resident. Eligibility if you have or are eligible for other coverage Eligibility if you are covered under another individual health benefits plan - You and/or Your Dependents are eligible for coverage under this Contract if this Contract replaces another Individual Health Benefits Plan under which You and/or Your Dependents are covered. You may request termination of the replaced Individual Health Benefits Plan pursuant to the termination provisions of that Plan. We may require proof that the other coverage has been terminated. Eligibility if you are eligible for coverage under a U.S. Citizen, National, group health benefits plan - You and/or Dependents may be eligible for coverage under this Contract only during the open enrollment period which occurs each year during the month of November for an effective date of January 1 of the following year. Consult Us or lawfully present in the United States]Your agent for more information. Adding dependents to this contract Spouse - You may apply to add Your Spouse by notifying Us in writingwriting at any time. You must submit an application to Us to change Your type of coverage. If Your application is made and submitted to Us within 60 31 days of Your marriage or documentation of domestic partnership or civil union, the Spouse will be covered. as covered from the date of the first [or fifteenth] of the month following the date We receive the application. In case of a court order, coverage of a spouse as required by a court order will be effective as of the date specified in the court orderSpouse’s eligibility. If You We do not submit an application receive Your written notice within 60 31 days of Your Spouse becoming eligible, You may apply to add coverage for Your Spouse during an Annual Open Enrollment Period or during an applicable Special Enrollment Periodwill not become effective immediately. Rather, such coverage will become effective on the first day of the month after the date Your application is received. Newborn Children - We will cover Your newborn child for 31 days from the date of birth without additional premium. Coverage may be continued beyond such 31-day period as stated below: If You are already covered for Dependent child coverage on the date the child is born, coverage automatically continues beyond the initial 31 days, provided the premium required for Dependent child coverage continues to be paid. You must notify Us of the birth of the newborn child as soon as possible in order that We may properly provide coverage under this Contract. If You are not covered for Dependent child coverage on the date the child is born, You must: a) give written notice to enroll the newborn child; and b) pay any additional the premium required for Dependent child coverage within 60 31 days after the date of birth for coverage to continue beyond the initial 31 days. If the notice is not given and the premium is not paid within such 6031-day period, the newborn child’s coverage will end at the end of such 31-day period. If the notice is given and the premium paid after that 31-day period, such coverage will become effective on the first day of the month after the date Your application is received. Child Dependent - If You may apply for have Single or Two Adult Coverage and want to add a child Dependent, other than a Newborn Child, You must change to Family Coverage or Adult and Child(ren) Coverage. To change coverage, You must submit an application. If Your application is made and submitted to Us within 31 days of the child's becoming a Dependent, the Child will be covered from the date of his or her eligibility. Even if You have Family Coverage or Adult and Child(ren) Coverage, however, You must give Us written notice that You wish to add a child. If Your written notice to add a child is made and submitted to Us within 31 days of the Child's becoming a Dependent, the Child will be covered from the date of eligibility. If We do not receive Your written notice within 31 days of Your Dependent's becoming eligible, coverage for that Dependent will not become effective immediately. Rather, such coverage will become effective on the Child during an Annual Open Enrollment Period or during any applicable Special Enrollment Periodfirst day of the month after the date Your application is received.

Types of Coverage. The Contractholder who completes an application for coverage may elect coverage just for him/herself and may add one or more eligible Dependents for coverage. The possible types of coverage listed below: • Single Coverage - coverage under this Contract for only one person. • Family Coverage - coverage under this Contract for You, Your Spouse and Your Dependent child(ren). • Adult and Child(ren) Coverage - coverage under this Contract for You and Your Dependent child(ren) [or coverage for multiple children residing within the same residence who share a common legal guardian, or for when there exists a valid support order requiring health benefit coverage whether or not there is an adult who will be provided coverage]. • [Single and Spouse] [Two Adults] Coverage - coverage under this Contract for You and Your Spouse. Who is Eligible The Contractholder -You, if You are an Eligible Person, [who lives in the designated Service Area in the State of New Jersey]. Spouse - Your Spouse [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person except: a Spouse need not be a Resident; [but must be a U.S. Citizen, National or lawfully present in the United States].Child - Your child [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person and who qualifies as a Dependent, as defined in this Contract, except: a child need not be a Resident;[but must be a U.S. Citizen, National or lawfully present in the United States]. You may have an unmarried child with a mental or physical handicap, or developmental disability, who is incapable of earning a living. Subject to all of the terms of this section and the Contract, such a child may stay eligible for Dependent health benefits past this Contract's age limit for eligible Dependents. The child will stay eligible as long as the child is and remains unmarried and incapable of earning a living, if: a) the child's condition started before he or she reached this Contract's age limit; b) the child became covered under this Contract or any other policy or contract before the child reached the age limit and stayed continuously covered or covered after reaching such limit; and c) the child depends on You for most of his or her support and maintenance. But, for the child to stay eligible, You must send Us written proof that the child is incapacitated or developmentally disabled and depends on You for most of his or her support and maintenance. You have 31 days from the date the child reaches the age limit to do this. We can ask for periodic proof that the child's condition continues. But, after two years, We cannot ask for proof more than once a year. The child's coverage ends when Your coverage ends. In order to obtain and continue health care coverage with Us, the Member, who is not covered as either a Dependent Spouse or as a Dependent child, must be a Resident [and a U.S. Citizen, National, or lawfully present in the United States]. We reserve the right to require proof that such Member is a Resident[and a U.S. Citizen, National, or lawfully present in the United States]. Adding dependents to this contract Spouse - You may apply to add Your Spouse by notifying Us in writing. If Your application is made and submitted to Us within 60 days of Your marriage or documentation of domestic partnership or civil union, the Spouse will be covered. as of the first [or fifteenth] of the month following the date We receive the application. In case of a court order, coverage of a spouse as required by a court order will be effective as of the date specified in the court order. If You do not submit an application within 60 days of Your Spouse becoming eligible, You may apply to add coverage for Your Spouse during an Annual Open Enrollment Period or during an applicable Special Enrollment Period. Newborn Children - We will cover Your newborn child for 31 days from the date of birth without additional premium. Coverage may be continued beyond such 31-day period as stated below: You must: a) give written notice to enroll the newborn child; and b) pay any additional premium required for Dependent child coverage within 60 days after the date of birth for coverage to continue beyond the initial 31 days. If the notice is not given and the premium is not paid within such 60-day period, the newborn child’s coverage will end at the end of such 31-day period. You may apply for coverage for the Child during an Annual Open Enrollment Period or during any applicable Special Enrollment Period.

Types of Coverage. The Contractholder who completes an application for coverage may elect coverage just for him/herself and may add one or more eligible Dependents for coverage. The possible of the types of coverage listed below: • Single Coverage - coverage under this Contract for only one person. • Family Coverage - coverage under this Contract for You, Your Spouse You and Your Dependent child(renDependent(s). • Adult and Child(ren) Coverage - coverage under this Contract for You and all Your Dependent child(ren) [Child Dependents or coverage for multiple children residing within the same residence who share a common legal guardian, or for when there exists a valid support order requiring health benefit coverage whether or not there is an adult who will be provided coverage]. • [Single and Spouse] [Two Adults] Spouse Coverage - coverage under this Contract for You and Your Spouse. Who is Eligible The Contractholder -You, if You are an Eligible Person, [who lives lives, resides or works in the designated Service Area in the State of New Jersey]] except as provided below. Spouse - Your Spouse [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person except: a Spouse need not be a Resident; [but must be a U.S. Citizen, National or lawfully present in the United States].Child and except as provided below. Child - Your child [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person and who qualifies as a Dependent, as defined in this Contract, except: a child Child need not be a Resident;[but must be a U.S. Citizen, National or lawfully present in the United States]Resident; and except as provided below. You may have an unmarried child with a mental or physical handicap, or developmental disability, who is incapable of earning a living. Subject to all of the terms of this section and the Contract, such a child may stay eligible for Dependent health benefits past this Contract's age limit for eligible Dependents. The child will stay eligible as long as the child is and remains stays unmarried and incapable of earning a living, if: a) the child's condition started before he or she reached this Contract's age limit; b) the child became covered under this Contract or any other policy or contract before the child reached the age limit and stayed continuously covered or covered after reaching such limit; and c) the child depends on You for most of his or her support and maintenance. But, for the child to stay eligible, You must send Us written proof that the child is incapacitated or developmentally disabled and depends on You for most of his or her support and maintenance. You have 31 days from the date the child reaches the age limit to do this. We can ask for periodic proof that the child's condition continues. But, after two years, We cannot ask for proof more than once a year. The child's coverage ends when Your coverage ends. In order to obtain and continue health care coverage with Us, the Member, who is not covered as either a Dependent Spouse or as a Dependent childChild, must be a Resident [and a U.S. Citizen, National, or lawfully present in the United States]Resident. We reserve the right to require proof that such Member is a Resident[and Resident. Eligibility if you have or are eligible for other coverage Eligibility if you are covered under another individual health benefits plan - You and/or Your Dependents are eligible for coverage under this Contract if this Contract replaces another Individual Health Benefits Plan under which You and/or Your Dependents are covered. You may request termination of the replaced Individual Health Benefits Plan pursuant to the termination provisions of that Plan. We may require proof that the other coverage has been terminated. Eligibility if you are eligible for coverage under a U.S. Citizen, National, group health benefits plan - You and/or Dependents may be eligible for coverage under this Contract only during the open enrollment period which occurs each year during the month of November for an effective date of January 1 of the following year. Consult Us or lawfully present in the United States]Your agent for more information. Adding dependents to this contract Spouse - You may apply to add Your Spouse by notifying Us in writingwriting at any time. You must submit an application to Us to change Your type of coverage. If Your application is made and submitted to Us within 60 31 days of Your marriage or documentation of domestic partnership or civil union, the Spouse will be covered. as covered from the date of the first [or fifteenth] of the month following the date We receive the application. In case of a court order, coverage of a spouse as required by a court order will be effective as of the date specified in the court orderSpouse’s eligibility. If You We do not submit an application receive Your written notice within 60 31 days of Your Spouse becoming eligible, You may apply to add coverage for Your Spouse during an Annual Open Enrollment Period or during an applicable Special Enrollment Periodwill not become effective immediately. Rather, such coverage will become effective on the first day of the month after the date Your application is received. Newborn Children - We will cover Your newborn child for 31 days from the date of birth without additional premium. Coverage may be continued beyond such 31-day period as stated below: If You are already covered for Dependent child coverage on the date the child is born, coverage automatically continues beyond the initial 31 days, provided the premium required for Dependent child coverage continues to be paid. You must notify Us of the birth of the newborn child as soon as possible in order that We may properly provide coverage under this Contract. If You are not covered for Dependent child coverage on the date the child is born, You must: a) give written notice to enroll the newborn child; and b) pay any additional the premium required for Dependent child coverage within 60 31 days after the date of birth for coverage to continue beyond the initial 31 days. If the notice is not given and the premium is not paid within such 6031-day period, the newborn child’s coverage will end at the end of such 31-day period. If the notice is given and the premium paid after that 31-day period, such coverage will become effective on the first day of the month after the date Your application is received. Child Dependent - If You may apply for have Single or Single and Spouse Coverage and want to add a child Dependent, other than a Newborn Child, You must change to Family Coverage or Adult and Child(ren) Coverage. To change coverage, You must submit an application. If Your application is made and submitted to Us within 31 days of the child's becoming a Dependent, the Child will be covered from the date of his or her eligibility. Even if You have Family Coverage or Adult and Child(ren) Coverage, however, You must give Us written notice that You wish to add a child. If Your written notice to add a child is made and submitted to Us within 31 days of the Child's becoming a Dependent, the Child will be covered from the date of eligibility. If We do not receive Your written notice within 31 days of Your Dependent's becoming eligible, coverage for that Dependent will not become effective immediately. Rather, such coverage will become effective on the Child during an Annual Open Enrollment Period or during any applicable Special Enrollment Periodfirst day of the month after the date Your application is received.

Types of Coverage. The Contractholder who completes an application for coverage may elect coverage just for him/herself and may add one or more eligible Dependents for coverage. The possible types of coverage listed below: • Single Coverage - coverage under this Contract for only one person. • Family Coverage - coverage under this Contract for You, Your Spouse and Your Dependent child(renChild(ren). • Adult and Child(ren) Coverage - coverage under this Contract for You and Your Dependent child(renChild(ren) [or coverage for multiple children residing within the same residence who share a common legal guardian, or for when there exists a valid support order requiring health benefit coverage whether or not there is an adult who will be provided coverage]. • [Single and Spouse] [Two Adults] Spouse Coverage - coverage under this Contract for You and Your Spouse. Who is Eligible The Contractholder -You, if You are an Eligible Person, [who lives lives, resides or works in the designated Service Area in the State of New Jersey]. Spouse - Your Spouse [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person except: a Spouse need not be a Resident; [but must be a U.S. Citizen, National or lawfully present in the United States].Child - Your child [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person and who qualifies as a Dependent, as defined in this Contract, except: a child Child need not be a Resident;[but must be a U.S. Citizen, National or lawfully present in the United States]. You may have an unmarried child with a mental or physical handicap, or developmental disability, who is incapable of earning a living. Subject to all of the terms of this section and the Contract, such a child may stay eligible for Dependent health benefits past this Contract's age limit for eligible Dependents. The child will stay eligible as long as the child is and remains unmarried and incapable of earning a living, if: a) the child's condition started before he or she reached this Contract's age limit; b) the child became covered under this Contract or any other policy or contract before the child reached the age limit and stayed continuously covered or covered after reaching such limit; and c) the child depends on You for most of his or her support and maintenance. But, for the child to stay eligible, You must send Us written proof that the child is incapacitated or developmentally disabled and depends on You for most of his or her support and maintenance. You have 31 days from the date the child reaches the age limit to do this. We can ask for periodic proof that the child's condition continues. But, after two years, We cannot ask for proof more than once a year. The child's coverage ends when Your coverage ends. In order to obtain and continue health care coverage with Us, the Member, who is not covered as either a Dependent Spouse or as a Dependent childChild, must be a Resident [and a U.S. Citizen, National, or lawfully present in the United States]. We reserve the right to require proof that such Member is a Resident[and a U.S. Citizen, National, or lawfully present in the United States]. Adding dependents to this contract Spouse - You may apply to add Your Spouse by notifying Us in writingwriting at any time. You must submit an application to Us to change Your type of coverage. If Your application is made and submitted to Us within 60 31 days of Your marriage or documentation of domestic partnership or civil union, the Spouse will be covered. as covered from the date of the first [or fifteenth] of the month following the date We receive the application. In case of a court order, coverage of a spouse as required by a court order will be effective as of the date specified in the court orderSpouse’s eligibility. If You We do not submit an application receive Your written notice within 60 31 days of Your Spouse becoming eligible, You may apply to add coverage for Your Spouse during an Annual Open Enrollment Period or during an applicable Special Enrollment Periodwill not become effective immediately. Rather, such coverage will become effective on the first day of the month after the date Your application is received. Newborn Children - We will cover Your newborn child for 31 days from the date of birth without additional premium. Coverage may be continued beyond such 31-day period as stated below: If You are already covered for Dependent child coverage on the date the child is born, coverage automatically continues beyond the initial 31 days, provided the appropriate premium required for Dependent child coverage taking the additional Child into consideration continues to be paid. You must notify Us of the birth of the newborn child as soon as possible in order that We may properly provide coverage under this Contract. If You are not covered for Dependent child coverage on the date the child is born, You must: a) give written notice to enroll the newborn child; and b) pay any additional the premium required for Dependent child coverage within 60 31 days after the date of birth for coverage to continue beyond the initial 31 days. If the notice is not given and the premium is not paid within such 6031-day period, the newborn child’s coverage will end at the end of such 31-day period. If the notice is given and the premium paid after that 31-day period, such coverage will become effective on the first day of the month after the date Your application is received. Child Dependent - If You may apply for have Single or Single and Spouse Coverage and want to add a child Dependent, other than a Newborn Child, You must change to Family Coverage or Adult and Child(ren) Coverage. To change coverage, You must submit an application and necessary premium. If Your application is made and submitted to Us within 31 days of the child's becoming a Dependent, the Child will be covered from the date of his or her eligibility. Even if You have Family Coverage or Adult and Child(ren) Coverage, , You must give Us written notice that You wish to add a child. If Your written notice to add a child is made and submitted to Us within 31 days of the Child's becoming a Dependent, the Child will be covered from the date of eligibility provided the appropriate premium is paid. If We do not receive Your written notice within 31 days of Your Dependent's becoming eligible, coverage for that Dependent will not become effective immediately. Rather, such coverage will become effective on the Child during an Annual Open Enrollment Period or during any applicable Special Enrollment Periodfirst day of the month after the date Your application and premium is received.

Types of Coverage. The Contractholder who completes an application for coverage may elect coverage just for him/herself and may add one or more eligible Dependents for coverage. The possible types of coverage listed below: • Single Coverage - coverage under this Contract for only one person. • Family Coverage - coverage under this Contract for You, Your Spouse and Your Dependent child(ren). • Adult and Child(ren) Coverage - coverage under this Contract for You and Your Dependent child(ren) [or coverage for multiple children residing within the same residence who share a common legal guardian, or for when there exists a valid support order requiring health benefit coverage whether or not there is an adult who will be provided coverage]. • [Single and Spouse] [Two Adults] Coverage - coverage under this Contract for You and Your Spouse. Who is Eligible The Contractholder -You, if You are an Eligible Person, [who lives in the designated Service Area in the State of New Jersey]. Spouse - Your Spouse [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person except: a Spouse need not be a Resident; [but must be a U.S. Citizen, National or lawfully present in the United States].Child - Your child [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person and who qualifies as a Dependent, as defined in this Contract, except: a child need not be a Resident;[but must be a U.S. Citizen, National or lawfully present in the United States]. You may have an unmarried child with a mental or physical handicap, or developmental disability, who is incapable of earning a living. Subject to all of the terms of this section and the Contract, such a child may stay eligible for Dependent health benefits past this Contract's age limit for eligible Dependents. The child will stay eligible as long as the child is and remains unmarried and incapable of earning a living, if: a) the child's condition started before he or she reached this Contract's age limit; b) the child became covered under this Contract or any other policy or contract before the child reached the age limit and stayed continuously covered or covered after reaching such limit; and c) the child depends on You for most of his or her support and maintenance. But, for the child to stay eligible, You must send Us written proof that the child is incapacitated or developmentally disabled and depends on You for most of his or her support and maintenance. You have 31 days from the date the child reaches the age limit to do this. We can ask for periodic proof that the child's condition continues. But, after two years, We cannot ask for proof more than once a year. The child's coverage ends when Your coverage ends. In order to obtain and continue health care coverage with Us, the Member, who is not covered as either a Dependent Spouse or as a Dependent child, must be a Resident [and a U.S. Citizen, National, or lawfully present in the United States]. We reserve the right to require proof that such Member is a Resident[and a U.S. Citizen, National, or lawfully present in the United States]. Adding dependents to this contract Spouse - You may apply to add Your Spouse by notifying Us in writing. If Your application is made and submitted to Us within 60 days of Your marriage or documentation of domestic partnership or civil union, the Spouse will be covered. as of the first [or fifteenth] of the month following the date We receive the application. In case of a court order, coverage of a spouse as required by a court order will be effective as of the date specified in the court order. If You do not submit an application within 60 days of Your Spouse becoming eligible, You may apply to add coverage for Your Spouse during an Annual Open Enrollment Period or during an applicable Special Enrollment Period. Newborn Children - We will cover Your newborn child for 31 days from the date of birth without additional premium. Coverage may be continued beyond such 31-day period as stated below: You must: a) give written notice to enroll the newborn child; and b) pay any additional premium required for Dependent child coverage within 60 days after the date of birth for coverage to continue beyond the initial 31 days. If the notice is not given and the premium is not paid within such 60-day period, the newborn child’s coverage will end at the end of such 31-day period. You may apply for coverage for the Child during an Annual Open Enrollment Period or during any applicable Special Enrollment Period.

Types of Coverage. The Contractholder who completes an application for coverage may elect coverage just for him/herself and may add one or more eligible Dependents for coverage. The possible of the types of coverage listed below: • Single Coverage - coverage under this Contract for only one person. • Family Coverage - coverage under this Contract for You, Your Spouse You and Your Dependent child(renDependent(s). • Adult and Child(ren) Coverage - coverage under this Contract for You and all Your Dependent child(ren) [Child Dependents or coverage for multiple children residing within the same residence who share a common legal guardian, or for when there exists a valid support order requiring health benefit coverage whether or not there is an adult who will be provided coverage]. • [Single and Spouse] [Two Adults] Spouse Coverage - coverage under this Contract for You and Your Spouse. Who is Eligible The Contractholder -You, if You are an Eligible Person, [who lives lives, resides or works in the designated Service Area in the State of New Jersey]] except as provided below. Spouse - Your Spouse [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person except: a Spouse need not be a Resident; [but must be a U.S. Citizen, National or lawfully present in the United States].Child and except as provided below. Child - Your child [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person and who qualifies as a Dependent, as defined in this Contract, except: a child Child need not be a Resident;[but must be a U.S. Citizen, National or lawfully present in the United States]Resident; and except as provided below. You may have an unmarried child with a mental or physical handicap, or developmental disability, who is incapable of earning a living. Subject to all of the terms of this section and the Contract, such a child may stay eligible for Dependent health benefits past this Contract's age limit for eligible Dependents. The child will stay eligible as long as the child is and remains stays unmarried and incapable of earning a living, if: a) the child's condition started before he or she reached this Contract's age limit; b) the child became covered under this Contract or any other policy or contract before the child reached the age limit and stayed continuously covered or covered after reaching such limit; and c) the child depends on You for most of his or her support and maintenance. But, for the child to stay eligible, You must send Us written proof that the child is incapacitated or developmentally disabled and depends on You for most of his or her support and maintenance. You have 31 days from the date the child reaches the age limit to do this. We can ask for periodic proof that the child's condition continues. But, after two years, We cannot ask for proof more than once a year. The child's coverage ends when Your coverage ends. In order to obtain and continue health care coverage with Us, the Member, who is not covered as either a Dependent Spouse or as a Dependent childChild, must be a Resident [and a U.S. Citizen, National, or lawfully present in the United States]Resident. We reserve the right to require proof that such Member is a Resident[and Resident. Eligibility if you have or are eligible for other coverage Eligibility if you are covered under another individual health benefits plan - You and/or Your Dependents are eligible for coverage under this Contract if this Contract replaces another Individual Health Benefits Plan under which You and/or Your Dependents are covered. You may request termination of the replaced Individual Health Benefits Plan pursuant to the termination provisions of that Plan. We may require proof that the other coverage has been terminated. Eligibility if you are eligible for coverage under a U.S. Citizen, National, group health benefits plan - You and/or Dependents may be eligible for coverage under this Contract only during the open enrollment period which occurs each year during the month of November for an effective date of January 1 of the following year. Consult Us or lawfully present in the United States]Your agent for more information. Adding dependents to this contract Spouse - You may apply to add Your Spouse by notifying Us in writingwriting at any time. You must submit an application to Us to change Your type of coverage. If Your application is made and submitted to Us within 60 31 days of Your marriage or documentation of domestic partnership or civil union, the Spouse will be covered. as covered from the date of the first [or fifteenth] of the month following the date We receive the application. In case of a court order, coverage of a spouse as required by a court order will be effective as of the date specified in the court orderSpouse’s eligibility. If You We do not submit an application receive Your written notice within 60 31 days of Your Spouse becoming eligible, You may apply to add coverage for Your Spouse during an Annual Open Enrollment Period or during an applicable Special Enrollment Periodwill not become effective immediately. Rather, such coverage will become effective on the first day of the month after the date Your application is received. Newborn Children - We will cover Your newborn child for 31 days from the date of birth without additional premium. Coverage may be continued beyond such 31-day period as stated below: If You are already covered for Dependent child coverage on the date the child is born, coverage automatically continues beyond the initial 31 days, provided the premium required for Dependent child coverage continues to be paid. You must notify Us of the birth of the newborn child as soon as possible in order that We may properly provide coverage under this Contract. If You are not covered for Dependent child coverage on the date the child is born, You must: a) give written notice to enroll the newborn child; and b) pay any additional the premium required for Dependent child coverage within 60 31 days after the date of birth for coverage to continue beyond the initial 31 days. If the notice is not given and the premium is not paid within such 6031-day period, the newborn child’s coverage will end at the end of such 31-day period. If the notice is given and the premium paid after that 31-day period, such coverage will become effective on the first day of the month after the date Your application is received. Child Dependent - If You may apply for have Single or Two Adult Coverage and want to add a child Dependent, other than a Newborn Child, You must change to Family Coverage or Adult and Child(ren) Coverage. To change coverage, You must submit an application. If Your application is made and submitted to Us within 31 days of the child's becoming a Dependent, the Child will be covered from the date of his or her eligibility. Even if You have Family Coverage or Adult and Child(ren) Coverage, however, You must give Us written notice that You wish to add a child. If Your written notice to add a child is made and submitted to Us within 31 days of the Child's becoming a Dependent, the Child will be covered from the date of eligibility. If We do not receive Your written notice within 31 days of Your Dependent's becoming eligible, coverage for that Dependent will not become effective immediately. Rather, such coverage will become effective on the Child during an Annual Open Enrollment Period or during any applicable Special Enrollment Periodfirst day of the month after the date Your application is received.

Types of Coverage. The Contractholder who completes an application for coverage may elect coverage just for him/herself and may add one or more eligible Dependents for coverage. The possible types of coverage listed below: • Single Coverage - coverage under this Contract for only one person. • Family Coverage - coverage under this Contract for You, Your Spouse and Your Dependent child(renChild(ren). • Adult and Child(ren) Coverage - coverage under this Contract for You and Your Dependent child(renChild(ren) [or coverage for multiple children residing within the same residence who share a common legal guardian, or for when there exists a valid support order requiring health benefit coverage whether or not there is an adult who will be provided coverage]. • [Single and Spouse] [Two Adults] Spouse Coverage - coverage under this Contract for You and Your Spouse. Who is Eligible The Contractholder -You, if You are an Eligible Person, [who lives lives, resides or works in the designated Service Area in the State of New Jersey]. Spouse - Your Spouse [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person except: a Spouse need not be a Resident; [but must be a U.S. Citizen, National or lawfully present in the United States].Child - Your child [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person and who qualifies as a Dependent, as defined in this Contract, except: a child Child need not be a Resident;[but must be a U.S. Citizen, National or lawfully present in the United States]. You may have an unmarried child with a mental or physical handicap, or developmental disability, who is incapable of earning a living. Subject to all of the terms of this section and the Contract, such a child may stay eligible for Dependent health benefits past this Contract's age limit for eligible Dependents. The child will stay eligible as long as the child is and remains unmarried and incapable of earning a living, if: a) the child's condition started before he or she reached this Contract's age limit; b) the child became covered under this Contract or any other policy or contract before the child reached the age limit and stayed continuously covered or covered after reaching such limit; and c) the child depends on You for most of his or her support and maintenance. But, for the child to stay eligible, You must send Us written proof that the child is incapacitated or developmentally disabled and depends on You for most of his or her support and maintenance. You have 31 days from the date the child reaches the age limit to do this. We can ask for periodic proof that the child's condition continues. But, after two years, We cannot ask for proof more than once a year. The child's coverage ends when Your coverage ends. In order to obtain and continue health care coverage with Us, the Member, who is not covered as either a Dependent Spouse or as a Dependent childChild, must be a Resident [and a U.S. Citizen, National, or lawfully present in the United States]. We reserve the right to require proof that such Member is a Resident[and a U.S. Citizen, National, or lawfully present in the United States]. Adding dependents to this contract Spouse - You may apply to add Your Spouse by notifying Us in writingwriting at any time. You must submit an application to Us to change Your type of coverage. If Your application is made and submitted to Us within 60 31 days of Your marriage or documentation of domestic partnership or civil union, the Spouse will be covered. as covered from the date of the first [or fifteenth] of the month following the date We receive the application. In case of a court order, coverage of a spouse as required by a court order will be effective as of the date specified in the court orderSpouse’s eligibility. If You We do not submit an application receive Your written notice within 60 31 days of Your Spouse becoming eligible, You may apply to add coverage for Your Spouse during an Annual Open Enrollment Period or during an applicable Special Enrollment Periodwill not become effective immediately. Rather, such coverage will become effective on the first day of the month after the date Your application is received. Newborn Children - We will cover Your newborn child for 31 days from the date of birth without additional premium. Coverage may be continued beyond such 31-day period as stated below: If You are already covered for Dependent child coverage on the date the child is born, coverage automatically continues beyond the initial 31 days, provided the appropriate premium required for Dependent child coverage taking the additional Child into consideration continues to be paid. You must notify Us of the birth of the newborn child as soon as possible in order that We may properly provide coverage under this Contract. If You are not covered for Dependent child coverage on the date the child is born, You must: a) give written notice to enroll the newborn child; and b) pay any additional the premium required for Dependent child coverage within 60 31 days after the date of birth for coverage to continue beyond the initial 31 days. If the notice is not given and the premium is not paid within such 6031-day period, the newborn child’s coverage will end at the end of such 31-day period. If the notice is given and the premium paid after that 31-day period, such coverage will become effective on the first day of the month after the date Your application is received. Child Dependent - If You may apply for have Single or Single and Spouse Coverage and want to add a child Dependent, other than a Newborn Child, You must change to Family Coverage or Adult and Child(ren) Coverage. To change coverage, You must submit an application and necessary premium. If Your application is made and submitted to Us within 31 days of the child's becoming a Dependent, the Child will be covered from the date of his or her eligibility. Even if You have Family Coverage or Adult and Child(ren) Coverage, , You must give Us written notice that You wish to add a child. If Your written notice to add a child is made and submitted to Us within 31 days of the Child's becoming a Dependent, the Child will be covered from the date of eligibility provided the appropriate premium is paid. If We do not receive Your written notice within 31 days of Your Dependent's becoming eligible, coverage for that Dependent will not become effective immediately. Rather, such coverage will become effective on the Child during an Annual Open Enrollment Period or during any applicable Special Enrollment Periodfirst day of the month after the date Your application and premium is received.

Types of Coverage. The Contractholder who completes an application for coverage may elect coverage just for him/herself and may add one or more eligible Dependents for coverage. The possible types of coverage listed below: •  Single Coverage - coverage under this Contract for only one person. •  Family Coverage - coverage under this Contract for You, Your Spouse and Your Dependent child(renChild(ren). •  Adult and Child(ren) Coverage - coverage under this Contract for You and Your Dependent child(renChild(ren) [or coverage for multiple children residing within the same residence who share a common legal guardian, or for when there exists a valid support order requiring health benefit coverage whether or not there is an adult who will be provided coverage]. • [ Single and Spouse] [Two Adults] Spouse Coverage - coverage under this Contract for You and Your Spouse. Who is Eligible The Contractholder -You, if You are an Eligible Person, [who lives lives, resides or works in the designated Service Area in the State of New Jersey]. Spouse - Your Spouse [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person except: a Spouse need not be a Resident; [but must be a U.S. Citizen, National or lawfully present in the United States].Child - Your child [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person and who qualifies as a Dependent, as defined in this Contract, except: a child Child need not be a Resident;[but must be a U.S. Citizen, National or lawfully present in the United States]. You may have an unmarried child with a mental or physical handicap, or developmental disability, who is incapable of earning a living. Subject to all of the terms of this section and the Contract, such a child may stay eligible for Dependent health benefits past this Contract's age limit for eligible Dependents. The child will stay eligible as long as the child is and remains unmarried and incapable of earning a living, if: a) the child's condition started before he or she reached this Contract's age limit; b) the child became covered under this Contract or any other policy or contract before the child reached the age limit and stayed continuously covered or covered after reaching such limit; and c) the child depends on You for most of his or her support and maintenance. But, for the child to stay eligible, You must send Us written proof that the child is incapacitated or developmentally disabled and depends on You for most of his or her support and maintenance. You have 31 days from the date the child reaches the age limit to do this. We can ask for periodic proof that the child's condition continues. But, after two years, We cannot ask for proof more than once a year. The child's coverage ends when Your coverage ends. In order to obtain and continue health care coverage with Us, the Member, who is not covered as either a Dependent Spouse or as a Dependent childChild, must be a Resident [and a U.S. Citizen, National, or lawfully present in the United States]. We reserve the right to require proof that such Member is a Resident[and a U.S. Citizen, National, or lawfully present in the United States]. Adding dependents to this contract Spouse - You may apply to add Your Spouse by notifying Us in writingwriting at any time. You must submit an application to Us to change Your type of coverage. If Your application is made and submitted to Us within 60 31 days of Your marriage or documentation of domestic partnership or civil union, the Spouse will be covered. as covered from the date of the first [or fifteenth] of the month following the date We receive the application. In case of a court order, coverage of a spouse as required by a court order will be effective as of the date specified in the court orderSpouse’s eligibility. If You We do not submit an application receive Your written notice within 60 31 days of Your Spouse becoming eligible, You may apply to add coverage for Your Spouse during an Annual Open Enrollment Period or during an applicable Special Enrollment Periodwill not become effective immediately. Rather, such coverage will become effective on the first day of the month after the date Your application is received. Newborn Children - We will cover Your newborn child for 31 days from the date of birth without additional premium. Coverage may be continued beyond such 31-day period as stated below: If You are already covered for Dependent child coverage on the date the child is born, coverage automatically continues beyond the initial 31 days, provided the appropriate premium required for Dependent child coverage taking the additional Child into consideration continues to be paid. You must notify Us of the birth of the newborn child as soon as possible in order that We may properly provide coverage under this Contract. If You are not covered for Dependent child coverage on the date the child is born, You must: a) give written notice to enroll the newborn child; and b) pay any additional the premium required for Dependent child coverage within 60 31 days after the date of birth for coverage to continue beyond the initial 31 days. If the notice is not given and the premium is not paid within such 6031-day period, the newborn child’s coverage will end at the end of such 31-day period. If the notice is given and the premium paid after that 31-day period, such coverage will become effective on the first day of the month after the date Your application is received. Child Dependent - If You may apply for have Single or Single and Spouse Coverage and want to add a child Dependent, other than a Newborn Child, You must change to Family Coverage or Adult and Child(ren) Coverage. To change coverage, You must submit an application and necessary premium. If Your application is made and submitted to Us within 31 days of the child's becoming a Dependent, the Child will be covered from the date of his or her eligibility. Even if You have Family Coverage or Adult and Child(ren) Coverage, , You must give Us written notice that You wish to add a child. If Your written notice to add a child is made and submitted to Us within 31 days of the Child's becoming a Dependent, the Child will be covered from the date of eligibility provided the appropriate premium is paid. If We do not receive Your written notice within 31 days of Your Dependent's becoming eligible, coverage for that Dependent will not become effective immediately. Rather, such coverage will become effective on the Child during an Annual Open Enrollment Period or during any applicable Special Enrollment Periodfirst day of the month after the date Your application and premium is received.

Types of Coverage. The Contractholder who completes an application for coverage may elect coverage just for him/herself and may add one or more eligible Dependents for coverage. The possible types of coverage listed below: • Single Coverage - coverage under this Contract for only one person. • Family Coverage - coverage under this Contract for You, Your Spouse and Your Dependent child(ren). • Adult and Child(ren) Coverage - coverage under this Contract for You and Your Dependent child(ren) [or coverage for multiple children residing within the same residence who share a common legal guardian, or for when there exists a valid support order requiring health benefit coverage whether or not there is an adult who will be provided coverage]. • [Single and Spouse] [Two Adults] Coverage - coverage under this Contract for You and Your Spouse. Who is Eligible The Contractholder -You, if You are an Eligible Person, [who lives in the designated Service Area in the State of New Jersey]. Spouse - Your Spouse [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person except: a Spouse need not be a Resident; [but must be a U.S. Citizen, National or lawfully present in the United States].Child - Your child [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person and who qualifies as a Dependent, as defined in this Contract, except: a child need not be a Resident;[but must be a U.S. Citizen, National or lawfully present in the United States]. You may have an unmarried child with a mental or physical handicap, or developmental disability, who is incapable of earning a living. Subject to all of the terms of this section and the Contract, such a child may stay eligible for Dependent health benefits past this Contract's age limit for eligible Dependents. The child will stay eligible as long as the child is and remains unmarried and incapable of earning a living, if: a) the child's condition started before he or she reached this Contract's age limit; b) the child became covered under this Contract or any other policy or contract before the child reached the age limit and stayed continuously covered or covered after reaching such limit; and c) the child depends on You for most of his or her support and maintenance. But, for the child to stay eligible, You must send Us written proof that the child is incapacitated or developmentally disabled and depends on You for most of his or her support and maintenance. You have 31 days from the date the child reaches the age limit to do this. We can ask for periodic proof that the child's condition continues. But, after two years, We cannot ask for proof more than once a year. The child's coverage ends when Your coverage ends. In order to obtain and continue health care coverage with Us, the Member, who is not covered as either a Dependent Spouse or as a Dependent child, must be a Resident [and a U.S. Citizen, National, or lawfully present in the United States]. We reserve the right to require proof that such Member is a Resident[and a U.S. Citizen, National, or lawfully present in the United States]. Adding dependents to this contract Spouse - You may apply to add Your Spouse by notifying Us in writing. If Your application is made and submitted to Us within 60 days of Your marriage or documentation of domestic partnership or civil union, the Spouse will be covered. as of the first [or fifteenth] of the month following the date We receive the application. In case of a court order, coverage of a spouse as required by a court order will be effective as of the date specified in the court order. If You do not submit an application within 60 days of Your Spouse becoming eligible, You may apply to add coverage for Your Spouse during an Annual Open Enrollment Period or during an applicable Special Enrollment Period. Newborn Children - We will cover Your newborn child for 31 60 days from the date of birth without additional premium. Coverage may be continued beyond such 3160-day period as stated below: You must: a) must give written notice to enroll the newborn child; child and b) pay any additional premium required for Dependent child coverage must be paid within 60 days after the date of birth for coverage to continue beyond the initial 31 60 days. If the notice is not given and the premium is not paid within such 60-day period, the newborn child’s coverage will end at the end of such 3160-day period. You may apply for coverage for the Child during an Annual Open Enrollment Period or during any applicable Special Enrollment Period.

Types of Coverage. The Contractholder who completes an application for coverage may elect coverage just for him/herself and may add one or more eligible Dependents for coverage. The possible of the types of coverage listed below: • Single Coverage - coverage under this Contract for only one person. • Family Coverage - coverage under this Contract for You, Your Spouse You and Your Dependent child(renDependent(s). • Adult and Child(ren) Coverage - coverage under this Contract for You and all Your Dependent child(ren) [Child Dependents or coverage for multiple children residing within the same residence who share a common legal guardian, or for when there exists a valid support order requiring health benefit coverage whether or not there is an adult who will be provided coverage]. • [Single and Spouse] [Two Adults] Spouse Coverage - coverage under this Contract for You and Your Spouse. Who is Eligible The Contractholder -You, if You are an Eligible Person, [who lives lives, resides or works in the designated Service Area in the State of New Jersey]] except as provided below. Spouse - Your Spouse [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person except: a Spouse need not be a Resident; [but must be a U.S. Citizen, National or lawfully present in the United States].Child and except as provided below. Child - Your child [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person and who qualifies as a Dependent, as defined in this Contract, except: a child Child need not be a Resident;[but must be a U.S. Citizen, National or lawfully present in the United States]Resident; and except as provided below. You may have an unmarried child with a mental or physical handicap, or developmental disability, who is incapable of earning a living. Subject to all of the terms of this section and the Contract, such a child may stay eligible for Dependent health benefits past this Contract's age limit for eligible Dependents. The child will stay eligible as long as the child is and remains stays unmarried and incapable of earning a living, if: a) the child's condition started before he or she reached this Contract's age limit; b) the child became covered under this Contract or any other policy or contract before the child reached the age limit and stayed continuously covered or covered after reaching such limit; and c) the child depends on You for most of his or her support and maintenance. But, for the child to stay eligible, You must send Us written proof that the child is incapacitated or developmentally disabled and depends on You for most of his or her support and maintenance. You have 31 days from the date the child reaches the age limit to do this. We can ask for periodic proof that the child's condition continues. But, after two years, We cannot ask for proof more than once a year. The child's coverage ends when Your coverage ends. In order to obtain and continue health care coverage with Us, the Member, who is not covered as either a Dependent Spouse or as a Dependent childChild, must be a Resident [and a U.S. Citizen, National, or lawfully present in the United States]Resident. We reserve the right to require proof that such Member is a Resident[and Resident. Eligibility if you have or are eligible for other coverage Eligibility if you are covered under another individual health benefits plan - You and/or Your Dependents are eligible for coverage under this Contract if this Contract replaces another Individual Health Benefits Plan under which You and/or Your Dependents are covered. You may request termination of the replaced Individual Health Benefits Plan pursuant to the termination provisions of that Plan. We may require proof that the other coverage has been terminated. Eligibility if you are eligible for coverage under a U.S. Citizen, National, group health benefits plan - You and/or Dependents may be eligible for coverage under this Contract only during the open enrollment period which occurs each year during the month of November for an effective date of January 1 of the following year. Consult Us or lawfully present in the United States]Your agent for more information. Adding dependents to this contract Spouse - You may apply to add Your Spouse by notifying Us in writingwriting at any time. You must submit an application to Us to change Your type of coverage. If Your application is made and submitted to Us within 60 31 days of Your marriage or documentation of domestic partnership or civil unionpartnership, the Spouse will be covered. as covered from the date of the first [or fifteenth] of the month following the date We receive the application. In case of a court order, coverage of a spouse as required by a court order will be effective as of the date specified in the court orderSpouse’s eligibility. If You We do not submit an application receive Your written notice within 60 31 days of Your Spouse becoming eligible, You may apply to add coverage for Your Spouse during an Annual Open Enrollment Period or during an applicable Special Enrollment Periodwill not become effective immediately. Newborn Children - We Rather, such coverage will cover Your newborn child for 31 days from become effective on the date first day of birth without additional premium. Coverage may be continued beyond such 31-day period as stated below: You must: a) give written notice to enroll the newborn child; and b) pay any additional premium required for Dependent child coverage within 60 days month after the date of birth for coverage to continue beyond the initial 31 days. If the notice Your application is not given and the premium is not paid within such 60-day period, the newborn child’s coverage will end at the end of such 31-day period. You may apply for coverage for the Child during an Annual Open Enrollment Period or during any applicable Special Enrollment Periodreceived.

Types of Coverage. The Contractholder who completes an application for coverage may elect coverage just for him/herself and may add one or more eligible Dependents for coverage. The possible types of coverage listed below: • Single Coverage - coverage under this Contract for only one person. • Family Coverage - coverage under this Contract for You, Your Spouse and Your Dependent child(ren). • Adult and Child(ren) Coverage - coverage under this Contract for You and Your Dependent child(ren) [or coverage for multiple children residing within the same residence who share a common legal guardian, or for when there exists a valid support order requiring health benefit coverage whether or not there is an adult who will be provided coverage]). • [Single and Spouse] [Two Adults] Coverage - coverage under this Contract for You and Your Spouse. • Responsible Person and Children Coverage - coverage under this Contract for the Responsible Person’s Dependent Children or coverage for multiple children for whom the Responsible Person is the legal guardian. Who is Eligible to be Covered The Contractholder -You, if You are an Eligible Person, [who lives in the designated Service Area in the State of New Jersey]. Spouse - Your Spouse [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person except: a Spouse need not be a Resident; [but must be a U.S. Citizen, National or lawfully present in the United States].Child - Your child [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person and who qualifies as a Dependent, as defined in this Contract, except: a child need not be a Resident;[but must be a U.S. Citizen, National or lawfully present in the United States]. Children – A Responsible Person’s children who are Eligible Persons and who qualify as a Dependent, as defined in this Contract. Note: Children must be Residents [ and must be U.S. Citizens, Nationals or lawfully present in the United States]. You may have an unmarried child with a mental or physical handicap, or developmental disability, who is incapable of earning a living. Subject to all of the terms of this section and the Contract, such a child may stay eligible for Dependent health benefits past this Contract's age limit for eligible Dependents. The child will stay eligible as long as the child is and remains unmarried and incapable of earning a living, if: a) the child's condition started before he or she reached this Contract's age limit; b) the child became covered under this Contract or any other policy or contract before the child reached the age limit and stayed continuously covered or covered after reaching such limit; and c) the child depends on You for most of his or her support and maintenance. But, for the child to stay eligible, You must send Us written proof that the child is incapacitated or developmentally disabled and depends on You for most of his or her support and maintenance. You have 31 days from the date the child reaches the age limit to do this. We can ask for periodic proof that the child's condition continues. But, after two years, We cannot ask for proof more than once a year. The child's coverage ends when Your coverage ends. In order to obtain and continue health care coverage with Us, the Member, who is not covered as either a Dependent Spouse or as a Dependent child, must be a Resident [and a U.S. Citizen, National, or lawfully present in the United States]. We reserve the right to require proof that such Member is a Resident[and a U.S. Citizen, National, or lawfully present in the United States]. Adding dependents to this contract Spouse - You may apply to add Your Spouse by notifying Us in writing. If Your application is made and submitted to Us within 60 days of Your marriage or documentation of domestic partnership or civil union, the Spouse will be covered. as of the first [or fifteenth] of the month following the date We receive the application. In case of a court order, coverage of a spouse as required by a court order will be effective as of the date specified in the court order. If You do not submit an application within 60 days of Your Spouse becoming eligible, You may apply to add coverage for Your Spouse during an Annual Open Enrollment Period or during an applicable Special Enrollment Period. Note: This Spouse provision does not apply to a Responsible Person. Newborn Children - We will cover Your newborn child for 31 60 days from the date of birth without additional premium. Coverage may be continued beyond such 3160-day period as stated below: You must: a) must give written notice to enroll the newborn child; child and b) pay any additional premium required for Dependent child coverage must be paid within 60 days after the date of birth for coverage to continue beyond the initial 31 60 days. If the notice is not given and the premium is not paid within such 60-day period, the newborn child’s coverage will end at the end of such 3160-day period. You may apply for coverage for the Child during an Annual Open Enrollment Period or during any applicable Special Enrollment Period.

Types of Coverage. The Contractholder who completes an application for coverage may elect coverage just for him/herself and may add one or more eligible Dependents for coverage. The possible types of coverage listed below: • Single Coverage - coverage under this Contract for only one person. • Family Coverage - coverage under this Contract for You, Your Spouse and Your Dependent child(ren). • Adult and Child(ren) Coverage - coverage under this Contract for You and all Your Dependent child(ren) [or coverage for multiple children residing within the same residence who share a common legal guardian, or for when there exists a valid support order requiring health benefit coverage whether or not there is an adult who will be provided coverage]. • [Single and Spouse] [Two Adults] Spouse Coverage - coverage under this Contract for You and Your Spouse. Who is Eligible The Contractholder -You, if You are an Eligible Person, [who lives in the designated Service Area in the State of New Jersey]. Spouse - Your Spouse [who lives, resides or works lives in the designated Service Area in the State of New Jersey.], who is an Eligible Person except: a Spouse need not be a Resident; [but must be a U.S. Citizen, National or lawfully present in the United States].Child . Child - Your child [who lives, resides or works lives in the designated Service Area in the State of New Jersey.], who is an Eligible Person and who qualifies as a Dependent, as defined in this Contract, except: a child Child need not be a Resident;[but must be a U.S. Citizen, National or lawfully present in the United States]Resident. You may have an unmarried child with a mental or physical handicap, or developmental disability, who is incapable of earning a living. Subject to all of the terms of this section and the Contract, such a child may stay eligible for Dependent health benefits past this Contract's age limit for eligible Dependents. The child will stay eligible as long as the child is and remains unmarried and incapable of earning a living, if: a) the child's condition started before he or she reached this Contract's age limit; b) the child became covered under this Contract or any other policy or contract before the child reached the age limit and stayed continuously covered or covered after reaching such limit; and c) the child depends on You for most of his or her support and maintenance. But, for the child to stay eligible, You must send Us written proof that the child is incapacitated or developmentally disabled and depends on You for most of his or her support and maintenance. You have 31 days from the date the child reaches the age limit to do this. We can ask for periodic proof that the child's condition continues. But, after two years, We cannot ask for proof more than once a year. The child's coverage ends when Your coverage ends. In order to obtain and continue health care coverage with Us, the Member, who is not covered as either a Dependent Spouse or as a Dependent childChild, must be a Resident [and a U.S. Citizen, National, or lawfully present in the United States]Resident. We reserve the right to require proof that such Member is a Resident[and a U.S. Citizen, National, or lawfully present in the United States]Resident. Adding dependents to this contract contract: Spouse - You may apply to add Your Spouse by notifying Us in writing. .. If Your application is made and submitted to Us within 60 days of Your marriage or documentation of domestic partnership or civil union, the Spouse will be covered. covered as of the first [or fifteenth] fifteenth of the month following the date We receive the application. In case of a court order, coverage of a spouse as required by a court order will be effective as of the date specified in the court order. If You do not submit an application within 60 days of Your Spouse becoming eligible, You may apply to add coverage for Your Spouse during an Annual Open Enrollment Period or during an applicable Special Enrollment Period. Newborn Children - We will cover Your newborn child for 31 days from the date of birth without additional premium. Coverage may be continued beyond such 31-day period as stated below: You must: a) give written notice to enroll the newborn child; and b) pay any additional premium required for Dependent child coverage within 60 days after the date of birth for coverage to continue beyond the initial 31 days. If the notice is not given and the premium is not paid within such 60-day period, the newborn child’s coverage will end at the end of such 31-day period. You may apply for coverage for the Child during an Annual Open Enrollment Period or during any applicable Special Enrollment Period.

Types of Coverage. The Contractholder who completes an application for coverage may elect coverage just for him/herself and may add one or more eligible Dependents for coverage. The possible types of coverage listed below: • Single Coverage - coverage under this Contract for only one person. • Family Coverage - coverage under this Contract for You, Your Spouse and Your Dependent child(ren). • Adult and Child(ren) Coverage - coverage under this Contract for You and Your Dependent child(ren) [or coverage for multiple children residing within the same residence who share a common legal guardian, or for when there exists a valid support order requiring health benefit coverage whether or not there is an adult who will be provided coverage]). • [Single and Spouse] [Two Adults] Coverage - coverage under this Contract for You and Your Spouse. • Responsible Person and Children Coverage - coverage under this Contract for the Responsible Person’s Dependent Children or coverage for multiple children for whom the Responsible Person is the legal guardian. Who is Eligible to be Covered The Contractholder -You, if You are an Eligible Person, [who lives in the designated Service Area in the State of New Jersey]. Spouse - Your Spouse [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person except: a Spouse need not be a Resident; [but must be a U.S. Citizen, National or lawfully present in the United States].Child - Your child [who lives, resides or works in the designated Service Area in the State of New Jersey.], who is an Eligible Person and who qualifies as a Dependent, as defined in this Contract, except: a child need not be a Resident;[but must be a U.S. Citizen, National or lawfully present in the United States]. Children – A Responsible Person’s children who are Eligible Persons and who qualify as a Dependent, as defined in this Contract. Note: Children must be Residents [ and must be U.S. Citizens, Nationals or lawfully present in the United States]. You may have an unmarried child with a mental or physical handicap, or developmental disability, who is incapable of earning a living. Subject to all of the terms of this section and the Contract, such a child may stay eligible for Dependent health benefits past this Contract's age limit for eligible Dependents. The child will stay eligible as long as the child is and remains unmarried and incapable of earning a living, if: a) the child's condition started before he or she reached this Contract's age limit; b) the child became covered under this Contract or any other policy or contract before the child reached the age limit and stayed continuously covered or covered after reaching such limit; and c) the child depends on You for most of his or her support and maintenance. But, for the child to stay eligible, You must send Us written proof that the child is incapacitated or developmentally disabled and depends on You for most of his or her support and maintenance. You have 31 days from the date the child reaches the age limit to do this. We can ask for periodic proof that the child's condition continues. But, after two years, We cannot ask for proof more than once a year. The child's coverage ends when Your coverage ends. In order to obtain and continue health care coverage with Us, the Member, who is not covered as either a Dependent Spouse or as a Dependent child, must be a Resident [and a U.S. Citizen, National, or lawfully present in the United States]. We reserve the right to require proof that such Member is a Resident[and a U.S. Citizen, National, or lawfully present in the United States]. Adding dependents to this contract Spouse - You may apply to add Your Spouse by notifying Us in writing. If Your application is made and submitted to Us within 60 days of Your marriage or documentation of domestic partnership or civil union, the Spouse will be covered. as of the first [or fifteenth] of the month following the date We receive the application. In case of a court order, coverage of a spouse as required by a court order will be effective as of the date specified in the court order. If You do not submit an application within 60 days of Your Spouse becoming eligible, You may apply to add coverage for Your Spouse during an Annual Open Enrollment Period or during an applicable Special Enrollment Period. Note: This Spouse provision does not apply to a Responsible Person. Newborn Children - Except as stated below with respect to a newborn of a Responsible Person, We will cover Your newborn child for 31 60 days from the date of birth without additional premium. Coverage may be continued beyond such 3160-day period as stated below: You must: a) must give written notice to enroll the newborn child; child and b) pay any additional premium required for Dependent child coverage must be paid within 60 days after the date of birth for coverage to continue beyond the initial 31 60 days. If the notice is not given and the premium is not paid within such 60-day period, the newborn child’s coverage will end at the end of such 3160-day period. You may apply for coverage for the Child during an Annual Open Enrollment Period or during any applicable Special Enrollment Period.